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A comparison of the play performance of boys with autism and that of boys without disabilities in Taiwan
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A comparison of the play performance of boys with autism and that of boys without disabilities in Taiwan
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A COMPARISON OF THE PLAY PERFORMANCE OF BOYS WITH AUTISM AND THAT OF BOYS WITHOUT DISABILITIES IN TAIWAN by I-Ching Lee A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (OCCUPATIONAL SCIENCE) August 2003 Copyright 2003 I-Ching Lee Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 3116736 Copyright 2003 by Lee, I-Ching All rights reserved. INFORMATION TO USERS The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. ® UMI UMI Microform 3116736 Copyright 2004 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UNIVERSITY OF SOUTHERN CALIFORNIA The Graduate School University Park LOS ANGELES, CALIFORNIA 900894695 This dissertation, w ritten b y J — C h u Q , L a e U nder th e direction o f h . Q X - D issertation K Com m ittee, and approved b y a ll its members, has been p resen ted to and accepted b y The Graduate School, in p a rtia l. fu lfillm e n t o f requirem ents fo r th e degree o f DOCTOR OF PHILOSOPHY f o f Graduate S tu dies D a te August 12, 2 0 0 3 ______ DISSER TA H O N COMMITTEE ' ^ ......................................................... r— \ Chairperson ___ l : £ _ ..... U Xi/L ^ P A • Of- [XakLt- Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ii ACKNOW LEDGEMENTS This dissertation is dedicated to my entire family for their immense confidence and faith in me, particularly my parents, Wen-I Lee and Shu-Pin Chiu, for their unconditional love and support; my brilliant brother, I-Yun Lee, for his constant inspiration and the generous words of comfort, and my sweetest sister, I- Chen Lee, for her amazing patience and tolerance in standing of my miserable whimsicality and oddity. I would like to give my sincere appreciation to my mentor, professor Mei-Jin Chen Sea, Sc.D., who has always been the perfect role model and the compass of my life. She has also provided me with her enormous assistance and invaluable encouragement throughout my graduate studies, so that I am forever grateful. I would like to acknowledge my dissertation committee, the chair, Mary Lawlor, Sc.D, and committee members, Diane Parham, Ph.D, Ann Neville-Jan, Ph.D, Jack Turman, Ph.D, and Wendy Mack, Ph.D, for their knowledge and expertise in providing thorough guidance and insightful comments. In addition, I would like to express my gratitude to many special friends who accompanied me through the ups and downs of my study process. For all the sharing and caring, my friends, you surely have a special place in my heart and in my memories. Finally, I especially appreciate all the parents and children who willingly participated in the study and generously cooperated to make the research run so smoothly. Best wishes to all the parents and children on their lives to come. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. iii TABLE OF CONTENTS ACKNOWLEDGEMENTS ............... ii LIST OF TABLES ...... viii ABSTRACT ............. - ...... x CHAPTER I: INTRODUCTION TO THE PROBLEM ................ 1 Rationale of the Study ..... 4 Significance of the Study .................... ■ • • • • 6 Purpose of the Study ..................... 9 Research Questions .................... 10 Hypotheses ..................... 10 Definition of Terms................. 11 CHAPTER D: REVIEW OF THE LITERATURE.................... 13 The Significance of Play in Development................................. 14 Play and Linguistic Development ............................ 14 Play and Emotional Development....... ........................ 16 Play and Social Development ..... 18 Play and Cognitive Development...................... 21 Conceptual Development. ............... 21 Intelligence ......................... 23 Problem-Solving........................... 23 Divergent Thinking.................. 24 Play and Skill Acquisition ........ 25 Summary ............................. 27 Developmental Nature of Play..................................... 28 Cognitive Perspective........................ 29 Social Features of Play ..... 31 Humanistic Perspective ...... 33 Play in Occupational Science and Occupational Therapy.. ..... 36 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. iv Children’s Play in Taiwan...... ...... .............................. ....................... 42 Chinese Cultural Beliefs ...... ...................... ..................... . 42 Parenting and Early Childhood Education Philosophy in Taiwan. ............... 44 Children’s Play Behaviors and Forms in Taiwan........................... 47 Studies of Children’s Play In Taiwan.............. .................... ........... 51 Diagnosis, Classification, and Epidemiology of A utism ............... 57 Play in Children with Autism.................................................. 62 Social Interaction in P lay ................................ 62 Imitation and Symbolic Play .................................... 63 Patterns of Behavior, Interests, and Activities ......................... 69 The Use of PPS in Studying the Play of Children with Autism.. ............................................. 71 Conclusion ....................................................... 73 “Theory of Mind” Deficit in Autism ..................................... 74 CHAPTER III: METHODOLOGY... ......................................... 78 Introduction................................................................ 78 Conceptual Framework for the Study ................................ 78 Participants ........................................................ 79 Inclusion Criteria ....................................... 79 Exclusion Criteria ......................................... 81 Sample Size ...................................... 81 Instrumentation ....................................................... 82 Revised Knox Preschool Play Scale.................................... 82 Reliability ....................................... 86 Validity ........................................... 87 Reliability and Validity of PPS with Handicapped Children............................................... 87 Peabody Picture Vocabulary Test-Revised (PPVT-R).................... 89 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. V Chinese Version of Peabody Picture Vocabulary Test-Revised... ................................ 90 Standardization of the Chinese Version of PPVT-R......... 90 Reliability of the Chinese Version of PPVT-R.................... 91 Validity of the Chinese Version of PPVT-R ............... 91 Research Procedures .......................................... 92 Preparatory Phase ........................................... 92 Description of Training for Principal Investigator ..... 92 Description of Training for Research Assistants.... 93 Pilot Study ............................................. 94 Purpose of the Pilot Study ................................... 94 Conclusions of the Pilot Study ................... 96 Changes Research Design Based on Pilot Study ..... 97 Focused Phase ............................................ 100 Procedures for Subj ect Recruitment .......................... 100 Obtain Parental Consent ................................ 101 Focused Observation and Videotaping ........ 104 Data Recording... ................................................. 108 Videotaped Observation .................................... 109 Written Field Notes .................................... 110 Demographic Form ........................................................................... 110 Standardized Assessments .... ................................................. 111 Data Processing ......................................................... I l l Scoring the PPS ........................................... I l l Data Analysis ............................................ 113 CHAPTER IV: RESULTS/RESEARCH FINDINGS ........... 116 Description of Final Samples .................................. 116 Normal Samples ................................................ 116 Autistic Samples .................................. 117 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. vi Description of Observation Sites .... . 119 Normal Samples................ 119 Autistic Samples ...... ............................ ..................... . 121 Indoor Observations ..... 122 Outdoor Observations ............. 122 Demographics ........ 123 Results on Chinese Version of Peabody Picture Vocabulary Test-Revised .................................. .............. 131 Research Findings on Research Questions/Hypotheses ...... 136 Question 1/Hypothesis 1 ......... 136 Question 2/Hypothesis 2 ........... 142 Question 3/Hypothesis 3 ....... 154 Question 4/Hypothesis 4 ............................................. 158 CHAPTER V: DISCUSSION.................... 164 Performance of Taiwanese Subjects with Autism................... 165 Participation ..... 165 Pretense/Symbolic ................... 170 Material M anagement...................... 173 Space M anagement................. 182 Performance on PPVT-R ......................... 183 Secondary Analysis ...... 185 Summary ............. 190 Performance of Taiwanese Subjects without Disabilities............... 191 Participation ................... 191 Pretense/Symbolic ................. 193 Material Management ................ 195 Space M anagement ................ 197 Application of PPS in Taiwanese Population ................ 197 Direct Administration of PPS in Taiwanese Population 198 Modification and Refinement of PPS for Taiwanese Population .............. 199 Develop a New Assessment for Taiwanese Population ........... 200 Limitations ....... 201 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. vii Suggestions for Future Research ....... 204 IQ, MA, or Other Criteria on Group M atching ......... 204 Gender Variable ..... 205 Longitudinal Research ...... 205 Cultural, Environmental and Human Contexts ...... 206 Playfulness ..... 207 Conclusion ..................... 208 REFERENCES.................. 210 APPENDICES................................. 231 Appendix A: International Classification of Diseases (ICD-10)............ 231 Appendix B: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)..................... 233 Appendix C: Revised Knox Preschool Play Scale (PPS)........................ 234 Appendix D: Preschool Play Scale: Data Sheet............................... ....... 237 Appendix E: Introductory Brochure...... ...... 238 Appendix F: Screening Questions for Child’s Normalcy: Parent’s Interview Guide ................................ 240 Appendix G: Informed Consent........................................... 242 Appendix H: Demographic Information..................... 249 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. viii LIST OF TABLES Table 1: Approximate Sample Size Necessary to Achieve Selected Levels of Power as a Function of Estimated Effect Size for Test of Difference of Two M eans ........... 82 Table 2: Pilot Data .............................................................................. 95 Table 3: Subject Recruitment in the Data Collection Process ............. 119 Table 4: Characteristics and Family Demographic Information of Subjects ...... 125 Table 5: Mean Scores and Standard Deviation for Different Family Economical Levels of Boys without Disabilities on Preschool Play Scale by Category, Dimension, and Total Play A g e 129 Table 6: Mean Scores and Standard Deviation for Different Father’s Educational Levels of Boys without Disabilities on Preschool Play Scale by Category, Dimension, and Total Play A g e.......... 130 Table 7: Performance on Chinese Version of Peabody Picture Vocabulary Test-Revised for Boys with Autism and Boys without Disabilities ...... 133 Table 8: Mean Scores and Standard Deviations for Boys with Autism and Boys without Disabilities on Preschool Play Scale by Category, Dimension, and Total Play A ge ........ 137 Table 9: Mean Scores and Standard Deviations for Boys with Autism and Boys without Disabilities, Group of Ages 3-4 Years, on Preschool Play Scale by Category, Dimension, and Total Play A ge..................... 139 Table 10: Mean Scores and Standard Deviations for Boys with Autism and Boys without Disabilities, Group of Ages 4-5 Years, on Preschool Play Scale by Category, Dimension, and Total Play A ge ..... 140 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ix Table 11: Mean Scores and Standard Deviations for Boys with Autism and Boys without Disabilities, Group of Ages 5-6 Years, on Preschool Play Scale by Category, Dimension, and Total Play Age............. 141 Table 12: Difference between Chronological Age and Performance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Ages 3-6 Years ..... 144 Table 13: Difference between Chronological Age and Performance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Group of Ages 3-4 Years.... ......... 148 Table 14: Difference between Chronological Age and Performance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Group of Ages 4-5 Y ears ..... 150 Table 15: Difference Between Chronological Age and Performance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Group of Ages 5-6 Years...................... 152 Table 16: Comparison of the Correlation of Chronological Age with Scores on the Preschool Play Scale between Boys with Autism and Boys without Disabilities ........................ 157 Table 17: Discriminant Analysis Classification Results for Preschool Play Scale by Dimension and Total Play A ge 159 Table 18: Discriminant Analysis Classification Results for Preschool Play Scale by Category................... 160 Table 19: Classification Rates from Discriminant Analysis, for Preschool Play Scale by Dimension and Category..... .......... 161 Table 20: The Performance of the Subgroups in Boys with Autism and Boys without Disabilities on PPS and PPVT-R...................... 186 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. X ABSTRACT This study assessed the play performance of 37 boys with autism and 42 boys without disabilities, aged 3 to 5 years, in Taiwan. Play performance was determined from videotaped observation of boys playing in the naturalistic environment, and rated using the standardized instrument of the Revised Knox Preschool Play Scale (PPS). Results indicated that the autistic boys scored significantly lower than the normal boys on PPS and its four dimensions. Analyses demonstrated a significantly higher correlation between the PPS age scores and the chronological age in the normal boys than in the autistic boys. Discriminant analyses revealed that the age scores from PPS and its dimension of Space Management, Pretense/Symbolic, and Participation, each correctly classified the subjects into their actual groups with a high degree of precision (i.e., the classification rate ranged from .84 to .98). The score from Material Management dimension only correctly classified 67% of the subjects. The Chinese Version of Peabody Picture Vocabulary Test-Revised (PPVT-R) was administered to estimate subjects’ cognitive capability. O f 37 subjects with autism, only 15 subjects completed the test independently with a score over 70. An additional statistic was applied to compare the performance of this subgroup of autistic boys with their normal peers. Analysis indicated that this subgroup of autistic boys scored significantly lower on PPS and three of its four dimensions Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. xi (Material Management, Pretense/Symbolic, and Participation) than their normal peers did. However, caution should be given to the interpretation of these results since the cognitive functioning (as measured by PPVT-R) was significantly lower in this subgroup of autistic boys, as compared to the normal controls. This study broadened understanding of play performance in the Taiwanese population and was informative of the potential play deficiencies that may help explain a wide range of the impairments associated with autism. It also raised a number of concerns that demand future investigation. Some comments regarding the implication of the findings and the application of PPS in the Taiwanese population were directed to Taiwanese practitioners. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 CHAPTER I INTRODUCTION TO THE PROBLEM All children play and it is through play that they interact with their environment. Because play is so pervasive in children’s everyday life, it has been widely described as their primary occupation, particularly within the field of occupational science. For children, play is as necessary as air or food (Ferland, 1997), it is life itself (Ferland, 1997), and it is the best means and an essential way of making contact, learning, and interacting with the world (Alessandrini, 1949). Play is a complex phenomenon that is difficult to define and comprehend (Parham & Primeau, 1997). As Sutton-Smith (1997) has argued persuasively, ideas about play are presented with “rhetorics” that reflect the variations of scholarly disciplines, ideologies, and cultural preoccupations. Over the years, there has been a great deal of research published from a range of perspectives and disciplines on childhood play. The significance of play has been acknowledged universally. In the field of occupational science, play has been perceived as one of the primary occupations with which humans occupy their time, energy and resources (Kielhofner, 1985,1995), and has been viewed as a crucial topic for research and clinical practice. Occupational science is an emerging academic discipline referred to as “the systematic study of the human as an occupational being” (Clark et ah, 1991, p. 300). Occupational scientists are concerned with the unique role of occupation in human life and emphasize “the ability of humans throughout the life span to actively pursue Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 2 and orchestrate occupations” (Clark et al, 1991, p. 300). “Occupation” is the central construct for occupational science. Occupation here is defined as “chunks of culturally and personally meaningful activity in which humans engage that can be named in the lexicon of our culture” (Clark et ah, 1991, p. 301). Occupational scientists are particularly concerned with how occupations impact human development, adaptation, and health. From a developmental perspective, play significantly contributes to children’s development, daily functioning, and quality of life (to be reviewed later). It is obvious that with engagement in play, children can fulfill emotional desires and develop personal capacities such as linguistic, sensorimotor, cognitive, and social skills needed for promoting children’s health, growth, and adaptation. Therefore, play is an important medium in pediatric occupational therapy because of its role in children’s growth and development, and its ability to encourage interaction with the environment. Parham (1995) emphasized the importance of making occupation the primary unit of research analysis, in order to understand an occupation from an occupational science perspective. Thus, within the field of pediatrics, play in children should be a focus of research. Play development information is crucial for adults who work and play with growing children. Information about both developmental norms and milestones in play development is indispensable for creating developmentally appropriate play environments, and for making accurate predictions about how children will play. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3 Both kinds of information enhance our ability to comprehend and evaluate what takes place sequentially within a play episode, either for an individual child at a certain developmental level, or for a group of children of a given age composition. For occupational therapists in Taiwan, the need for information regarding play is particularly critical in two areas: (a) play behavior in Taiwanese children, and (b) play in children with autism. Occupational scientists need to understand more about the play behavior of children in order to understand its significance in children’s lives. Many studies have been done to indicate developmental benefits of play. However, little is known about the play behavior of children in Taiwanese society. Also, little emphasis has been placed on autistic children and the impact of disabilities on their play behavior within the Taiwanese culture. In addition, a systematic look at the play behavior of autistic children in contrast to that of children without disabilities has not been done in Taiwanese society. The objective of this study was to examine and compare the play performance o f boys diagnosed as having autistic disorder with that of boys without disabilities, 3 to 5 years old, in Taiwan. This study was conducted to identify and clarify the problems that individuals with autism have in their daily play performance in Taiwan. Through observations within natural settings, this study examined children’s play from a developmental standpoint. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4 Rationale o f the Study While “play” is an extremely complex subject that has a wide range of aspects and contextual variables, this study focused solely on the play performance of Taiwanese children. In the United States, countless books and articles have been devoted to address children’s play. Yet in Taiwan, literature on “play” from occupational science and occupational therapy perspectives, as well as the study of children as occupational beings, is limited. Through observations, the researcher in this study hoped to give professionals further insight into the complexity and richness of the play performance of Taiwanese children. Researchers are increasingly conducting studies on children’s play in relation to culture variables. Although there is a growing body of literature addressing cultural variations in play expression of young children, as well as cultural differences in childrearing and in early childhood educational beliefs and practices related to play, little is known about children’s play in the Taiwanese society. No research exists to date on children with autism in Taiwan, from occupational science and occupational therapy perspectives. This study was conducted to better understand the play behavior of children with autism, as well as children without disabilities, within Taiwanese culture. Another major area of concern in this study was the play behavior of children with autism. From the time of its first scientific description 60 years ago by Kanner (1943), autism has attracted the interest and concern of clinicians and researchers to a Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 5 remarkable degree. Autism is one of the most devastating chronic developmental disabilities because of the severe, complex, and unusual combinations of cognitive, social, behavioral, affective, and neurobiological impairments attributed to the disorder. Although many studies have been conducted from the perspectives of psychology, education, psychiatry, speech and language, nursing, pediatrics, neurology, genetics, social work, law, neuroradiology, and pharmacology, there are limited studies concerning play behaviors of children with autism from the perspective of occupational science and occupational therapy. Therefore, further examination is necessary. This study was conducted to clarify the problems that autistic boys have in play by comparing the appropriateness of their play performance with that of normally developing peers. The function of play in development has received considerable theoretical attention over the years, and researchers have explored the developmental benefit of play in many specific areas. They have focused on various domains of children’s growth including sensorimotor development, cognition, language, social, and emotional areas. In this study, with respect to a holistic approach of children’s play from an occupational science perspective, attention was given not only to the physical aspect of play, but also to the cognitive and social dimensions of play. Play has been described as contributing to child’s development and growth in all areas, as well as reflecting developmental stages. Yet most studies have been Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6 done within artificial and controlled settings, Very few studies on children’s play have been conducted within the context of their usual routines and natural settings. This study was designed to observe children’s play behavior during free play, both indoors and outdoors, in naturalistic or familiar environments, to ensure that their typical play behaviors could be observed. Since much of children’s everyday activity is centered around play, the study of their play behavior from an occupational science perspective is vital. This study was conducted to directly address children’s occupational play performance. Since occupational scientists are concerned with the individual as an occupational being, studying children’s play from an occupational science perspective can provide a comprehensive, unifying approach to the complexity of play and its importance in children’s lives. In addition, the better the understanding of play as a universal occupation, and the better the awareness of the nature of play, the more contributions occupational scientists can make to improve clinical occupational therapy practice and to promote the health and quality of children’s lives. Significance o f the Study In Taiwan there have been a handful of studies in other disciplines that attempt to investigate play in children. However, investigations addressing children’s play in the field of occupational therapy are almost nonexistent. This study was one of the first to address Taiwanese children’s play from occupational science and occupational therapy perspectives. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7 Occupational therapy has existed as a profession in Taiwan for about 30 years. Within occupational therapy practice in Taiwan, most theory, professional philosophies, frames of reference, therapeutic technologies and modalities, and assessment tools have been derived from the United States. Although pediatric occupational therapy practitioners in Taiwan have commonly incorporated “play” in therapy, their knowledge of the evaluative tools needed to assess play and their skills in evaluating individual’s play performance still remain limited. This study was meant to encourage professionals to use published or standardized assessments in evaluating child’s play. The Revised Knox Preschool Play Scale (PPS) (Knox, 1997) was used in this study. Although no research has been conducted to indicate the reliability and validity of this scale in the Taiwanese population, it was utilized in this study for several reasons. First of all, this study’s focus was consistent with what the play scale was designed to do: to investigate play behavior from a developmental viewpoint. This researcher believes that there are similarities and commonalities among most children’s developmental progress; thereby, this researcher felt confident in utilizing this developmental play scale with Taiwanese children. In addition, the developmental frame of reference is the perspective that Taiwanese practitioners are most familiar with. Second, the scale not only measured physical aspects but also social and cognitive aspects of play, which provided holistic insight into children’s play Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8 performance. Third, since the observations took place in a familiar and naturalistic environment, the children were observed and rated in a setting that was likely to capture their typical play performance behavior. Fourth, since the scale was comparatively simple to use, it could be introduced to Taiwanese practitioners as a feasible tool for further exploration in clinical application and research. In sum, the study’s intent was to introduce this published assessment to Taiwanese practitioners in evaluating individuals’ play, as well as to provide insight into how well this instrument could be applied to the Taiwanese population. In terms of occupational science and occupational therapy, the study of children’s play behavior is important because it broadens our understanding of the significance of play as children’s primary occupation. A holistic picture of children’s play enables us to best appreciate play’s significance and to refine our theories of practice. Furthermore, an in-depth understanding of play could also nurture occupational therapy practice. In the pediatric setting, occupational therapists have frequently used “play” for therapeutic intervention. This study provided insight into the importance of considering the play behavior of individuals with disabilities. Its intent was to facilitate the development of play-related therapeutic intervention for individuals with disabilities. The study was also meant to enhance the knowledge of practitioners who work with children with difficulties, as well as to provide them with relevant skills to address the children’s play capabilities within their therapeutic practice. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 9 In sum, this study provided occupational therapists with information regarding the play behavior of Taiwanese children with autism and Taiwanese children without disabilities. This study was the first in Taiwan to investigate the play behavior of children with autism from occupational science and occupational therapy perspectives. The comparison of the play of children with autism with that of children without disabilities will enhance understanding of the developmental deficits that are associated with autism and the effects of these deficits on play. This study of play performance of Taiwanese children will contribute to addressing children’s occupational function in play in the field of occupational therapy. Purpose o f the Study The objective of this study was to examine and compare the play performance of boys diagnosed as having autistic disorder with that of boys without disabilities, aged 3 to 5 years in Taiwan. The study was conducted to identify and clarify the problems that boys with autism in Taiwan have in their daily play performance by observing children’s play behavior within natural settings, from a developmental standpoint. The purposes of this study were as follows: (a) to determine if there was a significant difference between play developmental levels of boys with autism and boys without disabilities, (b) to reveal if there was a significant difference between the chronological age of the boys and their play developmental level, (c) to identify if the correlation between chronological age and play developmental levels was Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10 significantly higher with the group of boys without disabilities than with the group of boys with autism, and (d) to investigate if the scores from the Revised Knox Preschool Play Scale correctly classified or differentiated subjects into their actual groups. Research Questions The study addressed the following research questions: 1. Were there any significant differences in play performance, as measured by the Revised Preschool Play Scale (PPS), of Taiwanese boys with autism compared to boys without disabilities, aged 3 to 5 years? 2. Were there any significant differences between the developmental play age and chronological age of the children in each group? 3. Were the correlations between chronological age and play age, and between chronological age and dimension scores significantly higher within the group of boys without disabilities than within the group of boys with autism? 4. Did the total score from the PPS, as well as the scores for each of its four dimensions, correctly classify or differentiate subjects into their actual groups? Hypotheses The following hypotheses were tested in this study: 1. Significant differences would exist between boys without disabilities and boys with autism on the mean scores of the PPS, and its four dimensions (Space Management, Material Management, Pretense/Symbolic, and Participation). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 11 2. Significant differences would exist between the developmental play age and chronological age of the children, only in the group of boys with autism and not in the group of boys without disabilities. 3. The correlations between chronological age and play age, and between chronological age and dimension scores would be significantly higher within the group of boys without disabilities than within the group of boys with autism. 4. The total score from the PPS and the scores of its four dimensions would correctly predict group membership of the subjects. Definition o f Terms Boys without Disabilities: Male children, 3 to 5 years of age, who had not demonstrated any psychiatric, psychological, physiological, or neurological problems as judged by his parent with several screening questions. For example, the children could not have been receiving special therapeutic services and taking prescription medications (e.g., for hyperactivity, seizures) during the study. Boys with Autism: Male children, 3 to 5 years of age, who had received a psychiatric diagnosis of autistic disorder based on the criteria for diagnosis set forth in D SM IV (APA, 1994) by either a special interdisciplinary team of clinicians or a clinical psychologist. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 12 Developmental Play Ages: Developmental play age refers to the age level of a child’s play (Knox, 1974). In this study, developmental play age was defined as the total score on the Revised Preschool Play Scale (PPS) (Knox, 1997). Play Performance: In this study, this term was described using four dimensions from the PPS: (a) Space Management: The way a child learned to manage his or her body and the space around him or her, through the process of experimentation and exploration; (b) Material Management: The manner in which the child handled materials and the purposes for which he or she uses materials; (c) Pretense/Symbolic: The way children learned about the world through imitation and the development of the ability to understand and separate reality from make-believe; and (d) Participation: The amount and manner of interaction with persons in the environment and the degree of independence and cooperation demonstrated in play activities (Knox, 1997). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 13 CHAPTER II REVIEW OF THE LITERATURE The purpose of this chapter is to review theory and research knowledge on a number of relevant topics in the literature on children’s play. This chapter is divided into the following sections: (a) the significance of play in development, (b) the developmental nature of play, (c) children’s play in Taiwan, (d) play in children with autism, and (e) play in occupational science and occupational therapy. Play is one of the major occupations in which humans engage throughout the course of their lives (Kielhofner, 1985, 1995). Young children spend most of their time in play, and play has been described as the child’s major occupation (Reilly, 1974). Clark and others (1991) presented a multidimensional perspective to analyze the nature of an occupation. Clark and others (1991) stated that occupation could be explained through the substrates of form, function, meaning and context. Form included products, activities, properties and relationships to time and referred to output or occupational behavior. Function included purposes, process, and experience and was primarily related to throughput. Meaning included motivations and satisfaction, also related to throughput. Context denoted the individual’s environment and related to historical and societal views that affected input into the system. In the first two sections, the literature on play will be reviewed within the constructs of occupational form and function of play in the child’s lives. The Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 14 literature on play in this study will be focused in two areas: (a) the significance of play in children’s development, which is a perspective of occupational function of play in children’s lives; and (b) the developmental nature of play, which addresses the properties and relationships of play to time in terms of the construct of occupational form in occupational science. The Significance o f Play in Development In the last two decades, many researchers have attempted to show the relationship of play to various aspects of development and competence. Studies showed that the relationship between play and development was complex and reciprocal. Play reflected development as well as contributed to development. This section describes the research knowledge on the contribution of play to various domains of children’s development including, linguistic, emotional, social, cognitive, and skill acquisition areas. Play and Linguistic Development Play has an important role on facilitating such linguistic development as literacy learning (Christie, 1998). A longitudinal study has demonstrated that pretend play and cognitively challenging talk in preschool, influenced language and literacy skills in elementary school (Dickinson, 1994). In play, the communicative properties and the functional uses of language are demonstrated to the child (Neuman & Roskos, 1991). Moreover, the ideal opportunities for experimenting and practicing with emergent forms of language, are also provided to the child while the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 15 child plays in various contexts (Christie, 1991, 1995; Marrow, & Rand, 1991). Play can also be viewed as an excellent means of fostering language mastery, such as sentence formation, encoding/decoding processes in reading, recall, story comprehension, and awareness of linguistic form (Fisher, 1992). Ungerer and Sigman (1984) finished a longitudinal study of the relationships of play and sensorimotor behavior to language among 39 subjects at 13.5- and 22 months. They concluded that the child’s ability to use symbols learned from play experience, served as a means of language development (e.g., interact and communicate with others). Another longitudinal study of 30 children at 20 and 28 months, about combinatorial abilities in language and symbolic play, was done by Shore, O ’Connell, and Bates (1984). They asserted that the child’s length of utterance, and referential and grammatical morpheme language were predicted by combinatorial sequences involving object substitutions in play. A positive correlation among combinatorial play, conceptual development, and early multiword speech, was found in Shore’s (1986) study on 30 children aged from 82 to 91 weeks. Combinatorial play is defined as symbolic play combined with appropriate symbolic themes. Shore concluded that the complexity of symbolic play with ‘‘counter-conventional’’ toys and the number of different block structures the child built, could be used to predict the children’s multiword performance, which required more symbolic development or memory and ability to use symbols independently. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 16 Athey (1988) described the relationships of play to both language comprehension and production. She felt that repetition was the intrinsic element of play at the sensorimotor stage that enhanced mastery of specific skills both in exploration and in language. Barnett (1990a, 1990b) described the common elements of play and language as (a) communication and sharing with others, and (b) learning about symbolic transformations and self-other relationships. She stated that the social interaction in play appeared to be necessary for the normal course of language growth. In sum, play is a valuable context for emerging and constructing linguistic concepts. Play also offers the rich opportunities to experiment with emergent forms of language and to achieve the maturation of linguistic mastery. Thus, play contributes significantly to children’s linguistic development. Play and Emotional Development In play, children explore not only their physical environment, but also their emotional and social environments (Goldstein, 1995). Play is an arena for promoting children’s emotional growth. According to Zillmann (1987), entertainment including play, is a means for achieving emotional and physiological self-regulation. Play occurs because it provides the players with satisfying levels of stimulation. This can be seen as a form of self-regulation of arousal states (Zillmann, 1987) and a regulation of affect (Fisher, 1992). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 17 Freud (1961) proposed two functions of play for children: (a) wish fulfillment and (b) mastery of events. He believed that children satisfied their needs and overcame the traumatic past experience by taking an active role in self-created play environment. Erikson (1963) elaborated Freud’s concept and asserted that children developed their coping strategies for anxieties and uncertainty, and enhanced their ability to master reality through self-created play situations. Similarly, Goldstein (1995) suggested that children not only imitate adult behaviors or create new actions for human adaptation in play; they might seek out a means of coping with anxiety, fear, and loss. In other words, play enables children to experience a level of stimulation, arousal, and affect most appropriate or comfortable at the moment. Thus, children play because it produces relaxation or excitement, encourages activity or passivity, solitude or sociality (Goldstein, 1995). Play is a safe context in which children can completely express all parts of self, and adequately express emotional reactions, thoughts, concerns, needs, and feelings that they cannot verbalize, or are frightening to express directly. When children are allowed control over their own play and feel safe, they can suspend reality and reflect on their inner life, respond to life’s challenges, heal hurts, release emotions, dissolve tensions, master traumatic experience, reconstruct conflictual feelings, and release anxiety through the process of symbolic representation and the act of repetition in play (Landreth & Homeyer, 1998; Schaefer, 1993). This is coherent with Freud’s argument about the characteristics of child’s play that “every Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 18 child at play behaves like an imaginative writer, in that he creates a world of his own, or more truly, he arranges the things of this world and orders it in a new way that pleases him better” (Freud, 1958, p. 45). Moreover, Landreth and Homeyer (1998) asserted that children develop emotional awareness, emotional strength and stability, spontaneity, senses of happiness, senses of humor, sensitivity, and empathy, in play. For example, in McGhee’s (1984) study of the importance of free play in children’s development of humor, the amount of time children spent in social play contributed strongly to the amount of children’s laughter and humor initiation. Additionally, some of children’s emotional needs such as curiosity; exploration; coping; anxiety and fear reduction; and self regulation of cognitive, emotional, and physiological states could be fulfilled through play (Goldstein, 1995; Zillmann, 1987). Therefore, play is “the language of children’s feelings’ (Landreth & Homeyer, 1998, p. 193), the way of child’s “self- expression” (Ferland, 1997, p. 11), and a major contributor of the child’s emotional growth. In other words, obviously from an occupational science viewpoint, one of the functions of play would be to promote emotional development and adaptation (e.g., emotional awareness, strength and fulfillment; self-regulation of affect and arousal states; development of copying strategies and defensive mechanisms, etc.). Play and Social Development Play in childhood, is a medium for socialization (Schwartzman, 1978). Ember and Ember (1988) described socialization as “the development, through the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 19 influence of parents and others, of patterns of behavior in children that conform to cultural expectations” (Ember & Ember, 1988, p. 402). Lenski and Lenski (1982), who are sociologists, described socialization as “the process through which individuals become functional members of their society” (Lenski & Lenski, 1982, p. 31). Hess (1970), who is a psychologist, described socialization as “the patterns of antecedent variables which shape behavior and tie it to the social system in which an individual lives” (Hess, 1970, p. 457). Schwartzman (1978) cited George Herbert Mead’s ideas that play permits children to imagine themselves in various social roles and opportunities have been offered for children to assume their own role/relationship to all of the other players when they play with their peers in games. Thus, it may be necessary to suppress one’s own identity for the sake of the team. When a child can accomplish this, he or she is well along in becoming a functional member of society. Furthermore, children appear to use play to establish self-identity by identifying with a positive reference group (same sex peers or same age peers), by distinguishing themselves from a negative reference group (such as parents or children of the opposite sex), and by eliciting predictable reactions from others (such as approval or disapproval from teachers or parents) (Goldstein, 1995). Similarly, Fagot and Leve (1998) believed play has a vital role on children’s gender identification of themselves. In play, children organize and integrate information to enrich knowledge about distinction of gender differences, identification of gender, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 20 meanings and expectations of gender in social context. As children play, their awareness of social role and social interactive skills are enhanced in conjunction with decreased egocentrism (Fisher, 1992). Nevertheless, play is a predictor or contributor to some aspects of the children’s social competence, such as affiliation and popularity with peers and social problem-solving flexibility (Pellegrini, 1995). An argument that children learn, develop, and practice cooperative ventures, dominance status, forms of social interaction, prosocial or antisocial behaviors and flexible social problem strategies through play has been supported by Pellegrini’s (1995) study. Moreover, Vandell (1979) proposed a positive effect of playgroup experience on social skill enhancement. The children in the playgroup became more active to their parent-child interaction. In Connolly and Doyle’s (1984) study of the relation of social fantasy play to social competence, results indicated the amount and complexity of fantasy play strongly contributed to teacher ratings of peer social skill, popularity, affective role taking, and a behavioral summary score reflecting positive social activity. MacDonald and Parke (1984) also found that parental physical play, engagement, and maternal verbal behavior, were positively related to the children’s peer relations in their study of the relations of parental physical play and the children’s social competence. MacDonald (1987) studied rejected, neglected, and popular children to clarify the role of parent-child physical play on the child’s social Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 21 competence. Results showed fathers of neglected boys engaged in less physical play than the fathers of rejected and popular boys. The rejected boys suffered more over stimulation and avoidance of stimulation, compared with the popular boys. Occupational scientists are eager to clarify the connection between occupation and the human’s social adaptation. The contribution of play in social development and competency, might serve as an example to understand how the individual’s occupation and adaptation could be constructed and studied in research. Play and Cognitive Development Many researchers acknowledge the contribution of play in the child’s cognitive development. Research linking play with four areas of cognitive development: (a) conceptual development, (b) intelligence, (c) problem-solving, and (d) divergent thinking are reviewed below. Conceptual development. In play, children develop their sensorimotor schemata and a concept of self through the feedback from the physical environment (Piaget, 1962). Simultaneously, in play, children begin distinguishing means and ends, self and others, human and nonhuman objects, then establish or form concepts regarding the properties of objects and object permanence (Piaget, 1962; Pierce, 1997). Smilansky (1968) has argued that sociodramatic play helps children integrate experiences that are separate and seem unrelated at first, such as selecting food and paying money to the cashier. Saltz, Dixson, and Johnson (1977), reported that Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 22 sociodramatic play and thematic fantasy play helped preschool children from impoverished backgrounds connect discrete events. Compared to the control group, those trained to engage in sociodramatic play and thematic fantasy play had significantly higher scores on sequencing and comprehension tests that required both a reconstruction of the order of pictures representing a story line and an explanation of the relationship among the pictures. In 1979, Bums and Brainerd investigated the effects of constructive and dramatic play on perspective taking. They found that both constructive and dramatic play have an important role on perspective taking. Ghiaci and Richardson (1980) emphasized the importance of dramatic play on the child’s cognitive ability to categorize and to structure. Sutton-Smith (1971) felt that play facilitated the development of representational sets or categories. He described four ways of playing that he felt corresponded to cognitive processes: (a) exploration in play leads to analytical thinking, (b) testing leads to prediction, (c) imitation leads to modeling, and (d) construction leads to the development of constructs and building. Play is also a medium for cultural transformation, cultural innovation, and information transmission (Huizinga, 1955). In play, a behavior pattern or context usually is attributed to the young, leading to consequent information distribution between generations (Huizinga, 1955). For example, children received the values (e.g., industry, obedience, responsibility, self-reliance, honesty, trust, etc.) from parents and develop their own values shown in play. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 23 Intelligence. Piaget (1962) asserted that children are active explorers and experimenters who use play as a medium for gaining knowledge through a process of assimilation and accommodation. He believed children could integrate knowledge in their way and reflect their growing intellect. Through play, children can integrate the expression of the cognitive process of assimilation and generate existing experiences to enhance the emergence of intelligence (Piaget, 1962). Research supports the possibility that play increases intelligence or general mental development. Correlational studies have revealed a positive relationship between IQ scores and two types of play: (a) sociodramatic play and (b) constructive play (Johnson, Ershler, & Lawton, 1982). Investigators have also found that play training positively affects children’s IQ scores. Children who initially exhibited low levels of sociodramatic play were taught how to engage in this type of play. Results showed that the training resulted in gains in both play and IQ scores (Saltz et al., 1977). Problem-solving. Bruner (1972) has theorized that play contributes to the children’s ability to solve problems by increasing their behavioral options. Athey (1988) felt that problem solving was enhanced through play in three ways: (a) encouragement of cognitive flexibility in solving problems, (b) assimilating information and working out problems through trial and repetition, and (c) generation of new problems. Rosen’s (1974) study of the effects of sociodramatic play on problem-solving indicated play contributed significantly to the child’s problem-solving behavior, cooperative effectiveness, and role-taking skills. Cheyne Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 24 (1982), Cheyne and Rubin (1983), and Rubin, Fein and Vandenberg (1983) studied relationships between play and problem solving ability by examining whether play with specific objects affected later problem solving. They found a significant correlation between the quality of play and the discovery of problem solutions. Divergent thinking. A number of correlational studies have established a positive relationship between play and various measures of creativity. Smilansky (1990) showed a relationship between sociodramatic play and cognitive tasks, particularly those of divergent thinking and intelligence. Lieberman (1977), Barnett and Kleiber (1982), and Truhon (1983) related characteristics of playfulness to divergent thinking and creativity. Schwartzman (1978) asserted that play serves as a form of communication. In play, communication occurs not only between generations, but also between children and the world. In play, children externalize their inner life and they further express, reflect, interpret, manipulate and construct ideas in novel ways from the children’s perspectives (Freud, 1958). Since play enables children to create and modify their perspective and skills, children have opportunities to combine or reconstruct the existing ideas to a new form of logical thinking that can contribute to the human’s creativity (Ferland, 1997; Lieberman, 1977) and adaptation (Bruner, 1972; Sutton-Smith, 1977). In other words, play serves as a medium for developing flexibility and contributes to human’s adaptation (Bruner, 1972; Sutton-Smith, 1977). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 25 In sum, play contributes to the development of child’s cognitive skills, including the understanding of abstract concepts (Piaget, 1962; Pierce, 1997), conceptual development (Bums & Brainerd, 1979; Ghiaci & Richardson, 1980; Huizinga, 1955; Piaget, 1962; Saltz et a l, 1977; Sutton-Smith, 1971), intelligence (Johnson et ah, 1982; Piaget, 1962; Saltz et ah, 1977), problem solving (Athey, 1988; Bruner, 1972; Cheyne, 1982; Cheyne & Rubin, 1983; Rubin et ah, 1983), divergent thinking (Barnett & Kleiber, 1982; Lieberman, 1977; Schwartzman, 1978; Smilansky, 1990; Truhon, 1983), and creativity and imagination (Piaget, 1962; Lieberman, 1977). Moreover, in Fisher’s (1992) analysis, play also promotes the child’s maturation of problem solving, cognitive control, cognitive functioning, cognitive structure, cognitive shifts, and perspective taking. Obviously, play is vital to the individual’s cognitive development, and occupational scientists are concerned with “the ways in which occupation serves adaptation” (Clark, Woods, & Larson, 1998, p. 18). In the area of cognitive function, play fosters the development of creativity, imagination, accommodation, assimilation, problem-solving, or cognitive constructions leading to enhance behavioral innovation and flexibility, and thus contributes to human adaptation. Play and Skill Acquisition In addition to several domains o f development addressed above, play in childhood can also be described as preparatory for the demands of adulthood, that is, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 26 developing skills needed for later in life (Mellon, 1994). The skills needed for later in life might include sensorimotor skills, both fine and gross motor skills, as well as other skills mentioned in the earlier section (e.g., social interactive skills, cognitive skills, linguistic skills). Reilly (1974) perceived play as exploratory learning of people, objects, movements, skills, and strategies. She believed the outcome of play is achieving competence and mastery through learning to symbolize, learning meaning, and learning later-needed skills. Hutt (1979) presented two major types of play based on the belief that play is an arena for learning and practicing skills. Epistemic play behavior is concerned with the acquisition of new information and knowledge. Ludic play behavior is performed by use of past experiences, which can be viewed as an arena for practicing acquired skills (Hutt, 1979). Several researchers addressed the power of play for enhancing development and skill acquisition (Florey & Greene, 1997; Mailloux & Burke, 1997; Neville-Jan, Fazio, Kennedy, & Snyder, 1997; Pierce, 1997). In the area of spatial skills, children obtain the spatial experiences (e.g., horizontal range, vertical levels, and active relations between objects), in play and develop the required spatial skills (e.g., precise manipulations of object combinations, understandings of large and detailed spatial layouts, and movement of objects through environmental space) (Pierce, 1997). Regarding temporal skills, play can be seen as a safe context where children can obtain temporal negotiation skills including the establishment of a biotemporal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 27 base rhythm (Pierce, 1997), differentiation between simultaneity and succession (Pierce, 1997), recognition of the temporal sequences in environmental events (Pierce, 1997), and action timing and sequencing (Mailloux & Burke, 1997). Furthermore, Mailloux and Burke (1997) and Pierce (1997) emphasized that children benefit from play with respect to the development of sensory and perceptual processes, including tactile perception, vestibular processing and balance, proprioceptive and kinesthetic perception, visual perception and coordination, auditory perception, and arousal. In addition, for children, play can provide the opportunities to develop or enhance motor skills such as stability, locomotion, object manipulation, strength, endurance, coordination, degree of dexterity, and the acquisition of tool use (Mailloux & Burke, 1997; Pierce, 1997). In general, major transformations in skills and capacities can take place during play and lead children to master the challenge from increasingly complex temporal, spatial, and social environments (Florey & Greene, 1997). Thus, play is an arena for promoting skill acquisition. Within the field of occupational science and occupational therapy, the development of the appropriate sensorimotor skills for the individual’s daily living, will influence an individual's optimal state of competency and mastery. Summary Johnson, Christie, and Yawkey (1999) have argued that there are three ways to consider the relationship of play with development (Johnson, Christie, & Yawkey, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 28 1999). First, the play behavior of the growing child may serve as a “window” in the child’s development revealing the current status of the child in various areas. That is, “play simply reflects development” (Johnson et ah, 1999, p. 26). Second, play may serve as a context and medium for the expression and consolidation of developmental acquisitions, be they behavioral skills or conceptual attainments, thus “play reinforces development” (Johnson et ah, 1999, p. 26). Third, play can serve as an instrument of developmental change. Play can generate qualitative improvements in the organism’s functioning and structural organization. In other words, “play can result in development” (Johnson et ah, p. 26). In this section, the research literature on the relationship between play and child development has been explored. Research evidence shows the importance of play for all areas of the children’s development including language, emotional, social, and cognitive development, as well as skill acquisition. Occupational scientists are particularly concerned about how occupation impacts health with respect to the function of occupation. Obviously, with engagement in play, human beings can fulfill emotional desires, and develop personal capacities such as language, sensorimotor, cognitive, and social skills needed for promoting humans’ health, growth, and adaptation. Developmental Nature o f Play As previously noted, it is believed that the play behavior of the growing child serves as a “window” in the child’s development revealing the current status o f the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 29 child in various areas (John et ah, 1999). In other words, play not only promotes the children’s development in all domains, play also demonstrates and reflects the children’s developmental level. The theoretical and empirical evidence concerning the relationship of play with development has been discussed in the previous section. In this section, another major aspect of the research literature, the developmental progressions with respect to play, in its own right, will be reviewed. Various authors have developed several theories and taxonomies. Some play theorists whose works have contributed to the development of the Revised Knox Preschool Play Scale were used in this study, and are important in their own right as well, will be discussed. Cognitive Perspective Many categorizations of play were formed as developmental hierarchies. As a noted psychologist, Piaget (1962) proposed three stages of play development: (a) practice play (sensorimotor play), (b) symbolic and pretend play, and (c) games with rules. According to Piaget (1962), intellectual adaptations resulted from equilibrium between the processes of assimilation (the child takes a new situation and bends it too much toward one of his or her existing schemes), and accommodation (the child develops a new scheme in response to the reality of the situation). Play represents an imbalance or disequilibrium in which assimilation dominates accommodation (Piaget, 1962). The behavior resulting from this assimilation reflects the child’s level of development. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 30 Piaget (1962) specified four maturational levels of cognitive function: (a) sensorimotor: from birth to about 2 years where children leam about their environment directly through their sensations and motor responses; (b) pre- operational: from 2 to 7 years of age when children learn to systematically manipulate their environment; (c) concrete operational: from about 7 to 11 years when it is important for the acquisition of reversibility (allows child to develop more spatial awareness), spatial concepts, and rales; and (d) form al operational: begins around 11 years and extends to the teens, signaling the transition to mature thinking. Piaget’s (1962) play categories are counterparts of his developmental levels of cognitive function. The child from birth to 2 years of age is in the practice play category. Play as assimilation becomes the repetition of already acquired modes of behavior detached from the functional purpose under which the behavior was initially required. As the child repeats the behavior, the acquired skills become consolidated, and this consolidation is done by incorporating old skills into new ones and becomes competent (Piaget, 1962). From about 2 to 7 years of age, symbolic play is evident. This stage reflects the child’s ability to understand that one thing can stand for something else, and this form of play is reflected in an assimilative orientation to the environment (Piaget, 1962). The game-with-rules stage is seen among children ages 7 to 11 years. An assimilative orientation to reality is continued in this category. Rules result from the collective organization of activities, and thus carry with them a sense of social obligation (Piaget, 1962). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 31 Smilansky (1968) elaborated Piaget’s idea and proposed three developmental levels of play: (a) functional play: sensorimotor or practice play that consists of simple repetitive movements; (b) constructive play: manipulation of objects to construct or create something; and (c) dramatic play: recognition, acceptance, and conformity to rules imposed on an activity. Social Features o f Play Several theorists classify social play in terms of developmental sequences hierarchically (Erikson, 1963; Howes, 1980; Howes & Matheson, 1992; Iwanaga, 1973; Parten, 1932, 1933). Parten (1932) defines play as six sequential categories of social interaction: (a) unoccupied play: playing with one’s own body, random activity; (b) solitary play: plays alone and independently, different activity, no reference to others; (c) onlooker play: watching others but not entering into the situation; (d) parallel play: plays independently but near or among others, similar toys or activities, beside but not with; (e) associative play: plays with others, conversation is about common activity, but does not subordinate own interests to groups; and (f) cooperative play: activity is organized, differentiation of roles, complementing actions. Iwanaga’s (1973) four categories of play pertain to how an individual child structures the play situation in regard to other children: (a) independent: no involvement of peers in play; (b) parallel play: with peers; undifferentiated roles, roles enacted independently, close physical proximity, awareness of activity of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 32 others; (c) complementary: differentiated roles, enacted independently, some cooperation but each child engages in a different activity, little adjustment to others’ behavior; and (d) integrative: roles enacted interactively, intense awareness of others, adjustment of behavior to shifts in others’ complementary roles. Howes’ (1980) categories show increases in reciprocity, complexity of interaction within dyads: (a) parallel-engaged: in similar activities but not paying any attention to one another; (b) mutual regard: similar activities plus eye contact and awareness of each other, no verbalization or other social bids; (c) simple social: similar activities along with social bids such as talking, smiling, offering toys; (d) complementary: collaborating in the same activity with mutual awareness but no social bids; and (e) complementary reciprocal: collaborating in the same activity with social bids. Howes and Matheson’s (1992) categories indicated increases in reciprocity, complexity, and communication and meta-communication in dyads. The categories are as follows: (a) parallel play: in proximity and in similar activities but without notice or awareness of each other; (b) parallel aware play: in proximity and in similar activities with eye contact and mutual awareness; (c) simple social play: engaged in similar activities with eye contact and presence of social bids, talking, giving, holding, etc.; (d) complementary and reciprocal play: presence of social bid plus “action-based role reversals,” e.g., hide-and-seek, run-and-chase; (e) cooperative social play: enactment of organized constructive or sociodramatic play Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 33 with complementary roles and communication; and (f) complex social play: engagement in organized constructive or dramatic play with play communication, communication about the play, or meta-communication. Humanistic Perspective ih Erik Erikson was a great theorist who studied human nature in the early 20 century in Europe and was influenced by the work of Freud. He is viewed as the father of ego psychology and a pioneer of the humanistic school of thought (Clark et ah, 1985). Erikson (1963) discussed play as a sequential unfolding of psychosocial relationships. Stage one, the autocosmic stage, involves the child from birth to 15 months. Child’s play begins with and centers on his or her own body during this stage, and this stage consists at first in the exploration by repetition of sensual perceptions, of kinesthetic sensations, of vocalizations, etc.; and next, the child plays with available persons and things. Stage two, the microcosmic stage, ranges from 15 months to 3 years. In this stage, the child uses small toys and objects to play out themes, and begins to master the environment. The macrosphere, stage three, involves children from nursery school to 7 years. In this stage, the child’s play revolves around other children. It is a world shared with others. Initially, the child may regard other children as things that are objects, and run into them or inspect them. But as experiences increase, the child leams to participate in cooperative role taking. Stage four, called industry versus inferiority, spans from 7 years to preadolescence. The school-aged child leams the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 34 skills and tools of his or her culture. Mastery of tasks and the development of competency are intrinsic rewards. Identity versus role confusion, stage five, encompasses the adolescent years. The focus of play and activities is role identification and work-oriented tasks play a major role in the child’s life situation. Moreover, several authors described and framed play behavior with chronological age (Ferland, 1997; Gamer, 1998; Johnson, 1998; Manning, 1998; Pratt, 1989). Pratt (1989) synthesized the properties of activities, representative toys and play behaviors in her categories of exploratory play, symbolic play, creative play, and games that correspond to chronological age. Ferland (1997) summarized the sequential development of play from birth to 18 months, from 18 months to 3 years, and from 3 to 6 years. Recently, play behavior had been integrated and described from birth to age 4 (Gamer, 1998), from ages 4 to 18 (Johnson, 1998), and from ages 8 to 12 (Manning, 1998). In the occupational therapy literature, developmental hierarchies of play have also been described and will be reviewed later (Florey, 1971; Knox, 1968, 1974; Reilly, 1974; Takata, 1974). In sum, developmental change in play behavior can be described over very brief periods of time, and over much longer periods of time as well. Systematic change in play behavior can be discerned over very small periods of time within a single event. For example, children often explore single objects before combining or transforming objects. Tempo, intensity, variability, and styles of behavior can also change drastically over time. For example, children’s action patterns, postures and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 35 expressions may be stereotyped and rigid at first, but usually children exhibit a more relaxed playful approach to the novel toy and demonstrate considerable response variability when they grow up. Many taxonomies proposed by play theorists described sequential patterns and temporal fluctuations in play behavior or experience over very brief periods of time. Developmental change also means shifts in play behavior over much longer periods of time, as in age-related developmental stages of play. This perspective consisted of questions like what are recognizable stages and substages of play that unfolded over months or over years of the child’s life. Several play theorists proposed the taxonomy based on this viewpoint. Qualitatively different kinds of play are known to emerge in a stagelike fashion, such as the Piagetian play stages of sensorimotor play, symbolic play, and games with rules. Long-term developmental changes occur within each play category as well. The symbolic play exhibited by toddlers, for instance, is much less developed than the symbolic play displayed by the average kindergarten child. These developmental changes occurred within each play behavior category, while different play forms emerged sequentially forming larger developmental patterns. Play has been described as contributing to development in all areas, as well as reflecting on the developmental stages. In this section, the developmental nature of play, the development of play behavior, in its own sake, were presented from a variety of perspectives: Piaget, a psychologist, from a cognitive perspective; Erikson, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 36 a psychologist from a humanistic perspective; and several researchers’ conceptual analysis of social features of play. Although the theories differed, they all established that play does have developmental characteristics. Knowing the information about the developmental processes and sequences of play, positions us to better appreciate the significance of play within the context of the growing child. In addition, information about developmental characteristics in play development is crucial for creating developmentally appropriate play environments, and for making accurate predictions about how children will play. Also, the review in the developmental nature of play can further enhance our ability to comprehend and evaluate what takes place sequentially within a play episode. Play in Occupational Science and Occupational Therapy Occupational science is an academic discipline, the purpose of which is to generate knowledge about the form, the function, and the meaning of human occupation. Clark and others (1991) defined occupation as “the chunks of culturally and personally meaningful activity in which humans engage” (p. 310). In occupational science, work, self-maintenance, leisure, play and rest are considered to be major occupations of people. People create or orchestrate their daily experiences through planning and participating in occupations. Occupations shape the quality of one’s life as well. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 37 Occupational science provides a foundation for the practice of occupational therapy, and occupation is the central construct for study in occupational science (Clark et ah, 1991). Play is one of the major occupations in which humans engage throughout the course of their lives (Kielho&er, 1985, 1995). Mary Reilly is a person who emphasized the worthiness of study on play in the field of occupational therapy, and further guided many of her graduate students during the 1960s and 1970s to focus on the study of play. Florey (1971), Takata (1974), and Knox (1968, 1974), made major contributions in the field of occupational therapy related to play under Reilly’s guidance. Reilly (1974) classified play as exploratory learning and hypothesized that play contributed to the development of competency. She conceptualized play stages in terms of the expression of the level of excitement and the requirement of the degree of control. She defined play as a multidimensional system for adaptation to the environment and felt that the exploratory drive of curiosity underplayed play behavior. This drive had three hierarchical stages: (a) exploratory behavior was seen mostly in early childhood and was fueled by intrinsic motivation; (b) competency behavior was characterized by experimentation and practice in order to achieve mastery; and (c) achievement behavior was linked to goal expectancies and fueled by a desire to achieve excellence. Knox (1968, 1974) developed a taxonomy of preschool children’s play from birth to 6 years that was recently revised (Knox, 1997). In the revision of the scale, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 38 she described the developmental sequence of play in four dimensions: (a) Space Management, (b) Material Management, (c) Pretense/Symbolic, and (d) Participation. In order to measure play performance of children in the present study, this Revised Knox Preschool Play Scale was used and will be described in more detail later. Florey (1971) and Takata (1974) also formulated developmental taxonomies of play based on elements of play, action on human and nonhuman objects, and on Piaget’s stages. Florey (1971) developed a classification system that organizes the developmental sequences of play behaviors according to variation in actions with human and nonhuman objects. Actions with human objects include play with parents, peers, significant others, and the child’s own body. Nonhuman objects are divided into three groups according to the inherent properties of the object for change as a result of the child’s actions. Type I objects include creative and unstructured media that can be directly changed by the playful actions of the child. Type II includes objects than can be changed when combined with other objects. Objects that maintain their original form in relatively stable condition regardless of play actions, such as bicycles and dolls, are referred to as Type III. Differential and preferential engagement in play with human and nonhuman objects varies over the course of time. Takata (1974) proposed that play evolves through a sequence of age-related epochs, The epochs were constructed around developmental age and milieu. Milieu Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 39 included materials, actions, people, and setting. These epochs are: (a) sensorimotor epoch: during the period from birth to 2 years; (b) symbolic and simple constructive epoch: at ages 2 to 4 years; (c) dramatic, complex, constructive and pregame epoch: at ages 4 to 7 years; (d) game epoch: during the period from 7 to 12 years; and (e) recreation epoch: in adolescenthood. Recently, Parham (1995) suggested that the best strategy for studying occupation is to make it the primary unit of analysis in research. Thus, if people want to understand play as an occupation, they study play directly. For example, Primeau’s (1995) study on the orchestration of parent-child play within the context of daily routines in the home, provided a great example of how to study “play” from an occupational science perspective (Primeau, 1995; Primeau, Clark, & Pierce, 1989). Bundy (1993) proposed that occupational therapists are unique in their perspective of play as an occupation. Bundy (1991) stated “occupational therapists make a living by creating ‘play’ and by enabling others to play” (p. 48). That is, occupational therapists provide services for clients by creating therapeutic situations in which the risks and consequences are minimized to allow them to try out or learn new skills and behaviors that they might not have chance to do in their normal lives. Schaaf and Mulrooney (1989) described the family-centered framework for occupational therapy service provision in pediatric settings. This framework is a synthesis of concepts from the Model of Human Occupation (Kielhofner & Burke, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 40 1980) and from the literature on play (Schaaf & Mulrooney, 1989). In this framework, play is used both as an evaluative tool and as an intervention modality that addresses the volition, habituation, and performance of the child and family as well as the strengths and weaknesses of the context of their life’s environment (Schaaf & Mulrooney, 1989). In terms of intervention, occupational therapists can refer to the concept of play and handle it in three ways as follows when individuals are referred to occupational therapy (Morrison, Metzger, & Pratt, 1996). First, occupational therapists can provide an intervention by using play as therapeutic modality with a purpose of improving specific skills (i.e., fine motor, gross motor, cognitive and social skills) (Morrison, Metzger, & Pratt, 1996). Second, intervention can be designed to directly work on improving individual’s play skills. For example, therapists can create a play situation to provide opportunities for facilitating skills development, for increasing play experiences, for promoting the generalization of skills, for altering the individual’s preference, and for altering the environment to facilitate a match between preference and skills (Morrison, Metzger, & Pratt, 1996). Third, occupational therapy can provide an intervention focused on facilitating playfulness. This can be accomplished by setting the environment and facilitating internal locus of control, by building trust and challenging the child, and by facilitating incorporation of the playful attitude into other aspects of intervention (Morrison, Metzger, & Pratt, 1996). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 41 Couch, Deitz, and Kanny (1998) surveyed 224 pediatric occupational therapists regarding their knowledge of play, professional skills of addressing play, and use of play in various practice settings. Their study explored the role of play within current occupational therapy practice with pediatrics. The results indicated that although respondents were aware of the importance of play in motivating children and frequently used play as a treatment modality or reinforcer, they less frequently assessed play behaviors or wrote treatment goals and objectives related to play. The results suggested the need for emphasizing play in educational curricula, enhancing clinician’s knowledge and skills about play, improving clinician access to valid and reliable play assessments, and conducting studies to address the use and efficacy of play in occupational therapy practice. Florey (1981) and Bundy (1991) emphasized the importance of addressing play as a legitimate area within the occupational science and occupational therapy profession, and the need to elaborate professional efficacy through research. Researchers assert some constraints (e.g., negative attitudes toward play, more emphasis on neuromotor skill development, unfamiliar with play assessments, insufficient knowledge of play, role ambiguity in practice setting/facility, or reimbursement issues), may contribute to the lack of emphasis on play by pediatric occupational therapists (Anderson, Hinojosa, & Strauch, 1987; Bundy, 1992; Robinson, 1977; Vergara, 1993). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 42 In sum, play is so vital in children’s everyday lives, that it has been described as their primary occupation within the field of occupational science and occupational therapy. The study of children’s play behavior is important for occupational scientists because it can yield rich and valuable information to further our understanding of play’s natures and significance, thereby improving our professional theories and nurturing our clinical practice. Children’ s Play in Taiwan A great deal of literature concerning taxonomies of play and the significance of play has typically been based on studies of Western children. However, play is an expression of a particular culture— an important context or vehicle for cultural learning and transmission, as well as an indicator and reflection o f child development (Schwartzman, 1978). Obviously, it is necessary to extend the conceptual outlook on children’s play in various cultures to achieve a more comprehensive and integrated understanding of play phenomenon. In this proposed study, the play performance of children in the Taiwanese society will be the focus in order to expand the knowledge about children’s play in Taiwan. In order to understand the role of play in the Taiwanese children’s lives, a brief consideration is required to explain the Chinese cultural briefs about childrearing and educational philosophy. Chinese Cultural Beliefs Within the Chinese society, the spirit of Confucianism has been the most influential philosophy. Confucius’s educational ideal of humanism is to foster a Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 43 superior man who has the outstanding characteristics of filial piety, respect for the old, adherence to rules, and the virtue of submission and cooperation. As a result within the schools, the main aim of education is to raise obedient children who are capable of maintaining harmonious human relations. However, some of these traditional Chinese values are being transformed or adapted under the influence of Western philosophy by the younger generation of educators or parents. An interesting analysis arises from the work of Hofstede (1983) and Triandis and others (Triandis, 1991; Triandis, Bontempos, Villareal, Asai, & Lucca, 1988). They have argued that all cultures involve two organizational tendencies: (a) collectivism (structuring information around ingroups), and (b) individualism (structuring information around individuals). Although both patterns may occur within a society, different societies attach more importance to one or the other. Many Western nations tend to value individualism, with an emphasis on personal responsibility and achievement. Other collectivist societies such as China, stress the obligations of the citizen to her or his community, valuing loyalty, trust, and cooperation. These cultural orientations have consequences for socialization, leading to an emphasis on self-reliance for the individualist cultures, and social conformity for the collectivist (Triandis, 1991). Not surprisingly, the children of the different societies are immersed in very different value systems that may in turn lead to variations in the forms of behaviors. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 44 Based in large part on the individualism-collectivism dichotomy, Markus and Kitayama (1991) have elaborated on the relationship between cultures and the diverse kinds of self-concept/self-development. They believed self-development takes place through social interactions that are shaped by cultural values about the ideal nature of human existence (i.e., individualism versus collectivism). They proposed the existence of two distinct types of self: (a) the “independent self’ that seeks to become autonomous, and to realize its uniqueness and separateness from others, commonly found in Western cultures such as that of the United States; and (b) the “interdependent self’ that seeks to become a part of various interpersonal relationships, and to realize its similarity and connectedness with others, often found in East Asian cultures like that of China (Markus & Kitayama, 1991). As a result, it might be expected that the variations of the children’s behaviors represent the cultures they grow up within the terms of nature of individualism and collectivism. Parenting and Early Childhood Education Philosophy in Taiwan Tobin, Wu, and Davidson (1989) compared children in early childhood settings in the United States, Japan, and China. The results indicated that U. S. responses fell between those of Japan and of China on dimensions of play and academic values for preschoolers. For example, among respondents, 70% of the Japanese, 42% of the United States, and 25% of the Chinese had “opportunities for Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 45 playing with other children” as the top three reasons of having preschool in society, and 67% of the Chinese, 51% of the United States, and 2% of the Japanese, emphasized academic values during the early preschool years. In Confucian heritage cultures, in Chinese preschools, the focus on order and regimentation, academics, the earnestness and perseverance of teachers and students, health and hygiene, and the ethos of collectivity and group harmony, are the results of a union of traditional Chinese with the communist ideology of collectivism (Tobin et al., 1989). Preschools in Taiwan that were colonized by the Japanese for over 50 years now look like a cross between Mainland Chinese and Japanese preschools (Tobin et ah, 1989). Gardner (1989) described two contrasting beliefs about how children learn: (a) mimetic approach and (b) transformative approach. The “mimetic approach” views a parent or teacher as a repository of knowledge and children as vessels to be filled. This approach emphasizes children’s memorization of knowledge and practice of skills and endorses adult-directed instruction and adult selection of the child’s learning experiences (Gardner, 1989; Ho, 1994; Liu, 1986). In this view, the cultivation of basic skills is primary. In Confucian heritage cultures, children are expected to be taught a culturally defined body of knowledge and accept it without question (Ho, 1994). A precondition to the success of this approach is the children’s early mastery of impulse control because formal schooling is highly disciplined. Children’s activity or exploratory demands tend to be discouraged (Ho, 1994; Liu, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 46 1986). The “transformative approach” involves a parent or teacher as a facilitator who attempts to engage students through questioning and directing of their attention (Gardner, 1989). The cultivation of creative and expressive is primary. This view is typical of the American cultural view of education. Parents who embrace this view would favor a more play-oriented approach (Gardner, 1989). In sum, in the mimetic view, the parent is viewed as more directive and controlling, whereas the ideal child is more quiet and compliant. In the transformative view, the parent facilitates in a nondirective way, whereas the child is encouraged to show initiative and to be assertive and independent. Regarding the parenting style, Baumrind (1967) generally identified three different patterns of parenting style: (a) authoritarian: these parents are strict, assert their power freely, expect obedience, attempt to instill respect for authority, and tend to lack clarity, relying on orders rather than reasoning; (b) authoritative: these parents are affectionate, more supportive of the child’s autonomy and interests, and they take note of the child’s point of view; and (c) permissive: some of these parents are warm and indulgent, others are cooler, more remote, and lack interests in the child, and they have in common a high level of tolerance of the child’s impulses and activities. When teaching their children, the parents’ practices probably reflect their respective cultural beliefs regarding appropriate education. Liu (1986) described the educational systems in Confucian heritage cultures as authoritarian; that is, Chinese Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 47 parents’ teaching practices may reflect more authoritarian beliefs (Liu, 1986). However, in Taiwan, with the influence of Western views of parenting and childrearing styles, more and more educators and parents make the shift from authoritarian approach to authoritative childrearing styles, which are more communicative and democratic. In sum, with the influences from cultural philosophy and styles of adult parenting and childrearing, even though there are basic similarities and commonalties among all children, there is considerable individual variation in the children’s reactions to the demands placed on them. Children’ s Play Behaviors and Forms in Taiwan In Taiwanese society, some traditional play forms observed in children’s daily life have been passed down from generation to generation, and constitute a valuable set of cultural heirlooms. Despite the vicissitudes in history and despite regional variations, many of the traditional play forms we observe today do not differ materially from those of ancient time traced back hundreds or even thousands of years. More detailed information about these play forms are provided below. Firecrackers on New Year’ s Day (Li, 1996; Pan, 1994). In ancient times, people burned bamboo that burst with a popping sound in the yard on the first day of the Chinese New Year to scare away the legendary ghosts that haunted the mountains. Since the Song Dynasty, people have burned paper-wrapped gunpowder Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 48 as a substitute. The lighting of firecrackers then became a popular play form of children during the Chinese New Year. Paper cuttings to welcome spring (Li, 1996). Children cut small pieces of paper into patterns of birds, flowers, or swallow to be worn on the hair of the beauties or to be attached to flowers and plants to celebrate spring. This practice was originally a method of praying for luck and later became popular among Chinese children. Whipping the ox in early spring (Li, 1996). On the day at the beginning of spring, officials dress up to worship the god of farming. Afterwards, they whipped the clay ox with decorative rods and sticks, a symbolic gesture to urge tillage. Whipping a clay ox has been handed down as a play form. Lifting lanterns (Li, 1996; Pan, 1994). During the Lantern Festival, children make their own lanterns and lift the homemade lantern outside with peers at night. Apart from putting up, lifting, and appreciating the lanterns, activities such as solving lantern riddles, walking long distances to drive away all diseases, beating the peace drum, and performing the dragon dance, are also included during this traditional holiday. Floating river lanterns (Li, 1996). On the evening of July 15th of the lunar year, people float candlelit lanterns on the river. It was believed that the lanterns could illuminate the way out for ghosts and spirits in the nether world. The lanterns Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 49 were made in different shapes, but most of them were in the shape of a lotus, which signified the release of the souls of the dead from purgatory. Finger-guessing game (Li, 1996). Originally, this game was entertainment during a banquet in which players guessed the fingers they showed in turn and the loser will have to drink a cup of wine. However, the finger-guessing game has been modified over the years as a favorite game among Chinese children. Cricket fighting (Li, 1996). Children start catching crickets in autumn and keep them in bamboo containers, clay pots or jars. In ancient times, there were cricket-fighting pits where people gambled on the game. Cricket fighting then has become a popular entertainment activity among Chinese children. Kite-flying (Li, 1996; Pan, 1994). Kite flying has been a popular form of entertainment among Chinese children. In some places, people deliberately cut the string to let the kite go, because they believe in this way, that it will take away bad luck. Hand-shadow play and puppet drama (Li, 1996). Children’s different hand movements in the lamplight cast a myriad of dramatic shadows. Children manipulate the puppets with singing and reciting the lines to perform a puppet drama. Differentiated by the forms of the puppets and the methods of manipulation, the puppet drama can be divided into categories of “sack (or glove) puppet,” “string puppet,” and “rod puppet.” Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 50 Whipping a top (Li, 1996; Pan, 1994). A top is a wooden toy in the shape of a little copper bell, except that it is solid and it has no handle. A string is wound around it. Once the top is set on the ground, children whip it speedily to make the top spin quickly and silently on the ground. Stomping songs (Li, 1996). Children stamp the ground out with the rhythm of the song while singing and dancing. Other play forms including (a) chopsticks games, (b) Chinese chess, (c) cock kicking, (d) Chinese yo-yo, (e) rope jumping, (f) hide and seek, (g) hopscotch play, (h) rubber bands, (i) marble games, and (j) sand pocket games are favored by Chinese children (Pan, 1994). Therefore, Taiwan has some of the traditional play forms that are gradually vanishing, while others are still being performed by Taiwanese children nowadays. During recent years, increased affluence with imported toys or more technical goods may have provided a variety of play materials, and may lead to dramatic changes in children’s play behaviors. Even though some traditional play forms were handed down through the generations and are still exercised by children in Taiwan, lots of imported materials, and modem play forms that are influenced by Western culture, are indeed favored by Taiwanese children as well. Play activities/forms associated with specific cultures might influence development by affecting the type of play in which children usually engage and the content of their play. Variations of play activities may also directly affect development by providing opportunities for learning. At the same time, the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 51 children’s individual characteristics, such as developmental levels and play styles, have an effect on what activities are selected in play. This researcher believes that certain types of materials or play activities tend to elicit specific aspects of play. For example, play activities involving blocks, tinker toys, and Legos inspire constructive play, whereas dolls, dress-up clothes, and housekeeping props encourage make- believe. Play materials or activities can also affect the social quality of play, with some encouraging solitary play and others group play. They can also indirectly affect the children’s growth by stimulating developmentally important types of play. Studies o f Children's Play in Taiwan Children’s play preferences in Taiwan have been explored in recent years (Lee, 1973; Lu, 1978; He, 1990). Lee (1973) examined play interests among kindergarten children in the Taipei area. The results demonstrated that slides and swings were the children’s favorite play structures followed by kites, electrical toys, tricycles, and playing ball. Lu (1978) studied play preferences of 3- to 6-year-old children and found that storybooks, drawing materials, and blocks were the popular toys in kindergarten. More recently, He (1990) investigated play preferences among 72, 3- to 5- year-old preschoolers in the Kaohsiung area, and found that symbolic play materials (e.g., miniature cars, toy eating utensils and food, dolls, toy furniture, animal toys, puppets) were the children’s most favorite play materials, followed by structured- construction play materials (e.g., blocks, Legos, and puzzles), fluid-constraction play Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 52 materials (e.g., paint, water, or clay), sensorimotor play materials (e.g., slides, climbing frames, balance beams), and letters-numbers materials (e.g., materials designed/created to introduce shapes of letters or numbers). In addition, gender differences among children in their preference of play materials were noted in the studies above, consistent with Servin, Bohlin, and Berlin’s (1999) findings that the gender differences were observed, at all three ages, in one-, three-, and 5-year-olds’ toy-choice in a structured play-session. Clearly, these findings indicate a dramatic change of children’s play preferences in Taiwanese society across the past decades. Apparently, with the influence of industrialization and urbanization of Taiwanese society, the outdoor play area has been reduced and the children’s play patterns have been changed. Nowadays, children play indoors more than outdoors, and prefer playing with symbolic or structured construction play materials that only require limited space. It is very important for us to be aware of environmental influences on play. Thus, in recent years, some investigators in Taiwan have pointed out the impact of environmental factors in the children’s play behavior (Huang, 1987; Wang, P., 1994; Wang, Y., 1994). In general, the effects of broad physical characteristics of play settings, such as the amount of space available for play, how the space is arranged, the amount of equipment available, and the number of people in the setting have been reported for designing/creating safe and effective play environment. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 53 Another interesting concern of play research in Taiwan is the cultural perceptions of children’s play (Li, Bundy, & Beer, 1995; Pan, 1991, 1994). As a result of cultural heritages and traditional childrearing styles, in considering the children’s behavior in play, Taiwanese parents expressed considerable valuing of certain aspects, such as the children’s other-focused emotional expressions, well- coordinated physical movements, harmonious cooperation in play, sharing toys, and they expressed relatively less value toward the children’s self-focused emotional expressions, creativity and flexibility of thought, being a leader, and being physically active in play (Li, Bundy, & Beer, 1995). In Confucian heritage cultures, quiet, compliant, shy, reticent, inhibited children are believed to be well-behaved (Ho, 1986), and are more likely to be accepted by their peers and to be nominated by teachers for positions of leadership and honorship (Chen, Rubin, & Li, 1995). Further, other-focused (e.g., sympathy, shame) rather than self-focused (e.g., self-satisfaction, self-confirmation) emotional expressions have been encouraged in Chinese society for the purpose of promoting interpersonal harmony (Markus & Kitayama, 1991). Subsequently, the spirit of Chinese culture emphasizes self-regulation, attention to and consideration of others. These concepts obviously differ from innovation, unique expression, and creativity that are individually centered (Liu, 1986). Consequently, it is not surprising that the items reflecting the nature of the traditional culture, such as responding easily, initiating play with others, cooperation Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 54 in play, sharing toys, expressing enjoyment, and showing enthusiasm in play, were valued as important by an overwhelming proportion of the Taiwanese parents. In other investigations of the adult’s perceptions toward children’s play, Pan (1991, 1994) reached similar conclusions with those of the above studies. Pan conducted a study o f 68 Taiwanese mothers’ attitudes toward preschoolers’ play, and found that the children’s cognitive development was rated as the top area in which play contributed, followed by social development, physical development, and mental development. A majority of the respondents reported that the constructive play (e.g., arithmetic and alphabetic play) was the predominant activity arranged for their children, which is consistent with He’s (1990) findings. This is not surprising because, traditionally, constructive activities or toys (e.g., blocks, Legos, and puzzles), requiring mature intellectual involvement have been perceived as an effective media for the children’s acquisition of skills, which might lead to higher academic achievements in school later. This may also result from insufficient play space with the increasing industrialization and the urbanization of Taiwanese society. Finally, with respect to Confucian heritage cultures, Chinese parents tended to discourage their children from conducting physically aggressive, risk-taking, or adventurous play (Ho, 1986). Thus, it is obvious that Chinese parents are more likely to encourage their children who are expected to be quiet, compliant, and highly disciplined to play with constructive toys. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 55 Pan (1991, 1994) also conducted an observational study of 62 kindergartners’ play behaviors in the current Taiwanese society. Three social play categories (i.e., solitary, parallel, interactive) modified from Parten’s (1932) developmental stage of social play and Smilansky’s (1968) cognitive play categories (i.e., functional, constructive, dramatic, and games with rules) were used to code play behaviors. Constructive play was found to be the most frequently occurring category of cognitive play, followed by functional play, dramatic play, and games with rules. Parallel play, followed by solitary play and interactive play, was the most frequently occurring play in terms of the social play category. In the social and cognitive play category, parallel-constructive play was the most frequently occurring behavior, followed by solitary-constructive play, solitary- functional play, parallel-functional play, interactive-dramatic play, interactive- functional play, parallel-dramatic play, interactive-constructive play, solitary- dramatic play, and interactive games with rules. Finally, the children’s mental age was significantly correlated with some play behaviors, whereas the children’s sex, IQ, and socioeconomic status were not found to be significantly correlated with play behaviors, which were consistent with Liu’s (1995) conclusions. Liu (1995) studied 58 kindergartners to examine the relationship among young children’s individual characteristics, playfulness and social play. With respect to the relationship between the subjects’ characteristics and social play, the findings were in agreement with Pan’s (1991, 1994) works. Furthermore, the results Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 56 indicated a significant positive relationship between the playfulness and social play of subjects with the good prediction of the subject’s social play by their level of playfulness. In comparing Pan’s (1991, 1994) findings with the results of Rubin and his colleagues’ (1976, 1978) studies, play behaviors performed by Taiwanese children do not deviate significantly from those of children in the Western Cultures in terms of the Parten and Smilansky’s framework. Constructive play was the predominant play displayed by children in Taiwan and America, but interactive dramatic play was exhibited more frequently (twice to thrice as much) in American children, whereas Taiwanese children engaged more on parallel-constructive play and interactive games with rules. In sum, even though the children behaved more and more similarly and predictably as they merge their play patterns, there is considerable variation and overlap in play expression among children across cultures. Increasingly, researchers have conducted studies on children’s play in relation to cultural variables. A growing body of literature documents wide cultural variations in the play expression of young children, as well as cultural differences in childrearing styles, and in early childhood educational beliefs and practices related to play and associated behaviors such as sports, games, projects, and so on (Roopnarine, Johnson, & Hooper, 1994). As yet, empirical works oriented toward children as occupational beings have not been extensively conducted among children in Taiwanese society. Therefore, for Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 57 reasons of enriching conceptualization directed toward the children’s occupations in Taiwan, serious attention should be focused on conducting research regarding children’s play within the Taiwanese culture. Diagnosis, Classification, and Epidemiology o f Autism Clinicians and researchers have achieved consensus on the validity of autism as a diagnostic category and on the many features central to its definitions (Rutter, 1996). This consensus has made possible the convergence of the two major diagnostic systems: the 4th edition of the Diagnostic and Statistical Manual o f Mental Disorders (DSM-IV) (American Psychiatric Association, APA, 1994), and the 10th edition of the International Classification o f Diseases iICD-10) (World Health Organization, WHO, 1992, 1993). In the first and second editions of the DSM (APA, 1952, 1968), only the term childhood schizophrenia was officially available to describe autistic children. In the DSM-III (APA, 1980), autistic children were classified as demonstrating infantile autism and those with a broader spectrum of the symptoms were referred to as showing pervasive developmental disorder (FDD). In the DSM-III-R (APA, 1987), the name of the condition was changed from Infantile Autism to Autistic Disorder to emphasize the persistence of the condition throughout the life span. The definition of autistic disorder in DSM-III-R consists of three major domains of dysfunction: (a) qualitative impairment in reciprocal social interaction; (b) qualitative impairment in verbal and nonverbal communication and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 58 in imagination; and (c) restricted repertoire of activities and interests. Sixteen proposed criteria for autistic disorder were grouped into the three broad categories. The diagnosis of autism required that an individual child or adult had to exhibit at least 8 of these 16 criteria in total, with a specified distribution over the three areas of disturbance (at least two symptoms from the social domain and one each from the communication and restricted activities categories) (APA, 1987). DSM-IV and ICD-10 are the most recent and most extensively evaluated diagnostic approaches for autism. The process of revision in the ICD-10 (WHO, 1992, 1993) was closely related to the development of the DSM -IV (APA, 1994). The International (ICD) and American (DSM) systems are fundamentally related and, by formal agreement, they must share to some degree, a common approach to diagnostic coding. ICD-10 was specially designed to have one set of research diagnostic criteria (WHO, 1993) and a separate set of clinical guidelines (WHO, 1992). In the initial version, the ICD-10 research definition of autism included 20 criteria. O f the original 20 ICD-10 criteria, four were identified for possible elimination. Alternatives to specific criteria were examined and a modified definition was developed (Appendix A). The diagnostic criteria for autism in DSM-IV provide reasonable coverage over the range of syndrome expression in autism and are applicable over the full life span from early childhood through adulthood. In DSM-IV, for the diagnosis of autism, at least six criteria must be exhibited, including at least two criteria relating Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 59 to social abnormalities and one each relating to impaired communication and range of interests and activities (Appendix B). In addition, the onset of the condition must have been prior to age three, as evidenced by delay or abnormal functioning in social interaction, language as used in social interaction, and symbolic/imaginative play. Qualitative impairment in social interaction can take the form of markedly impaired nonverbal behaviors, failure in developmentally expected peer relationships, lack of shared enjoyment or pleasure, or lack of socioemotional reciprocity (APA, 1994). Impairments in communication can take the form of delayed or lack of spoken language, impairment in conversational ability, stereotyped language, and deficits in imaginative play (APA, 1994). For persons with autism, the delay or lack of spoken language must not be accompanied by compensations through other communicative means such as gestures. The domain of restricted patterns of behavior, interests, and activities includes encompassing preoccupations that are abnormal in either focus or intensity, adherence to nonfunctional routines or rituals, stereotyped motor movements, and persistent preoccupation with parts of objects (APA, 1994). Official diagnosis and classification systems should be applicable to conditions that afflict individuals of different ages, developmental levels, and from different ethnic, social, and geographical backgrounds (Rutter, 1996). Today, there is broad agreement that autism is a developmental disorder; that autism and associated disorders represent the behavioral manifestations of underlying Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 60 dysfunctions, of generally undetermined etiology, in the neurobiological maturation and functioning of the central nervous system; and that sustained educational and behavioral interventions are useful and constitute the core of treatment (Bristol et al., 1996). The prevalence of Autistic Disorder is estimated at 4-5 {DSM-III-R, APA, 1987) and 2-5 {DSM-IV, APA, 1994) children per 10,000 individuals. Autistic Disorder is more common among males than females, where studies show ratios ranging from 2:1 to 5:1 (APA, 1987, 1994). Sometimes, the autistic condition is observed in association with other general medical conditions (e.g., encephalitis, phenylketonuria, tuberous sclerosis, fragile X syndrome, anoxia during birth, maternal rubella) (APA, 1994). In about 25% or more of cases of Autistic Disorder, seizures may develop by the time the person reaches adulthood (APA, 1987, 1994). In most cases, there is an associated diagnosis of Mental Retardation, commonly in the moderate range (IQ 35- 50) (APA, 1994). Females with the autistic disorder are more likely to exhibit more severe Mental Retardation (APA, 1994). Approximately, 70% of children with Autistic Disorder function at a retarded level (APA, 1994). Comprehensive reviews of existing research are provided by Gillberg (1991) and Venter, Lord, and Schopler (1992). Briefly, results indicated that outcomes in autism are generally poor. Few individuals (10% to 15%) had gainful employment, most required some degree of ongoing care or supervision, and as many as 50% Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 61 required a great deal of assistance. In the previous two decades, measures of educational attainment, employment status, self-sufficiency, and social adaptation suggest the outcomes in autism are better and evidence of improved outcomes has been linked to upgraded diagnostic, psychoeducational, and social services (Gillberg, 1991; Venter et al., 1992). In sum, in a real sense with a broad agreement among clinicians and researchers, autism is a developmental and lifelong disorder, and autistic individuals display abnormal functioning or impaired/delayed development in three major areas. First, individuals with autism demonstrate qualitative impairment in social interaction that can take the form of markedly impaired nonverbal behaviors, failure in developmentally expectable peer relationships, lack of shared enjoyment or pleasure, or lack o f socioemotional reciprocity. Second, there is qualitative abnormality in social communication as manifested in the form of delay or lack of spoken language, impairment in conversational ability, stereotyped language use, and deficits in imaginative play. Finally, the restricted, patterns of behavior, interests, and activities that was presented as the form of encompassing preoccupations that are abnormal in either focus or intensity, adherence to nonfunctional routines or rituals, stereotyped motor movements, and persistent preoccupation with parts of objects, are also observed in autistic individuals. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 62 Play in Children with Autism As noted in the previous section, it is not surprising that there are many behavioral difficulties associated with autism, have major impacts on play behaviors in autistic individuals. In the literature review in the following section, this researcher is focusing on three crucial domains of play in children with autism: (a) social interaction; (b) symbolic and imaginative play; and (c) patterns of behavior, interests, and activities. Each domain is considered in more detail below. Social Interaction in Play Children with autism often exhibit a larger number of social deficits as compared to normally developing peers. Problems in socialization are one of the main areas identified for the diagnosis of autism (APA, 1994; WHO, 1993). Autistic children display a variety of disorders in intellectual and social functioning, and their problems in social and affective functioning is observed in their unwillingness or ability to initiate and maintain social interchanges, and in the corresponding impairment of their communicative skills (Wing & Gould, 1979). Osterling and Dawson (1994) reviewed videotapes of 22 children (11 who were autistic and 11 who were developing normally), and found that the children with autism exhibited fewer social and joint-attention behaviors. They further suggested the behaviors such as pointing, showing objects, looking at others, and orienting in response to a name, could be used to differentiate the groups. Similarly, Gillberg and others (1990) reported that various social behaviors such as isolation, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 63 problems in eye contact and gaze, indifference to others, and problems in imitation, were more frequent in children who subsequently were identified as autistic than in normally developing children. With autism, a child may fail to show or point to objects or to gaze alternately at the interactive partner and a desired or interesting object/activity. Children with autism rarely initiate joint attention with their play partner as compared to children with mental retardation or children without dysfunction (Mundy, Sigman, Ungerer, & Sherman, 1987). Deficits in joint attention will influence the emergence of intersubjectivity, which is the most persistent problem in younger children with autism (Mundy, Sigman, Kasari, 1994; Sigman, Mundy, Sherman, & Ungerer, 1986). With respect to social interaction in play, children with autism were found to spend significantly more time in solitary play and display less interaction and communication with others than their normally developing peers (McHale, 1983). These results consistently supported a conclusion about autistic children’s difficulties in initiations and responses to interaction during play. Imitation and Symbolic Play It is a commonly held belief that autistic children are specially impaired in their ability to play symbolically (Jarrold, Boucher, & Smith, 1993; Wulff, 1985). The capacity to imitate appears to be a prerequisite for subsequent symbolic activities and children with autism display serious motor imitation deficits (Smith & Bryson, 1994). Many studies have shown that children with autism perform more Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 64 poorly on both the imitation of body movements and the imitation of actions with objects, as compared to control children with mental retardation (DeMyer et al., 1972; Sigman & Ungerer, 1984; Stone, Lemanek, Fishel, Fernandez, & Altemeier, 1990), and mental-age-matched typically developing children (Sigman & Ungerer, 1984). However, some evidence suggests that autistic individuals have at least some basic imitation skills, especially when familiar actions are used (Dawson & Adams, 1984). More recently, Charman and Baron-Cohen (1994) have demonstrated that autistic children are able to imitate both gestures and unfamiliar actions on objects. Loveland, Tunali-Kotoski, Pearson, Brelsford, Ortegon, and Chen (1994) have also shown good imitation of facial gestures in older autistic individuals. In addition, Libby, Powell, Messer, and Jordan (1997) have shown the autistic children’s certain capacity to imitate single pretend acts and a series of pretend acts. Thus, to date, autistic children have been rarely shown to imitate spontaneously. However, it is unclear whether the development of imitation abilities is simply delayed or is deviant in autism. Moreover, research has not clarified whether the problem with imitation in autistic individuals is attributable to difficulty in attending to, perceiving, remembering, comprehending, or executing the modeled action (Smith & Bryon, 1994). A growing body of research adds further support to the claim that autistic children demonstrate deficits in symbolic play (Jarrold, Boucher, & Smith, 1993; Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 65 Wulff, 1985). The play of autistic children is markedly different from the play of children with similar developmental abilities (Riquet, Taylor, Benaroya, & Klein, 1981). Young children with autism have shown evidence of a deficit in functional play in several studies. A group of 16 autistic children demonstrated less functional play in both unstructured and structured situations than a group of 16 mentally retarded children matched on mental and chronological age, and a group of 16 normal children matched on mental age (Sigman & Ungerer, 1984). In the unstructured situation, the autistic children engaged in less functional play and fewer sequences of three or more related functional acts than did the children in the other groups. Studies of older, more developmentally advanced groups have yielded mixed results. Baron-Cohen (1987) did not find differences in functional play in unstructured situations when autistic children were compared to a control group matched on verbal mental age. In Stone and others’ (1990) study of play and imitation in preschool groups of autistic, hearing impaired, language impaired, mentally retarded, and non-handicapped children, the autistic children spent less time playing than other groups and performed fewer functional acts than other children. In addition, there was no difference in the number of symbolic play acts, but significantly fewer autistic children engaged in symbolic play. With an even more developmentally advanced sample, Lewis and Boucher (1988) observed play in both structured and unstructured situations. The autistic Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 66 children had language abilities in the 4- to 5-year-old age range, and the control groups were matched on these language abilities. In the unstructured situation, the autistic children engaged in functional play less than the other two groups, although all but two of the autistic children engaged in at least some functional play. Almost all studies have shown fewer symbolic play-act by autistic children than by comparing children. Riguet and others (1981) observed play in 10 autistic children with verbal-MA-matched control groups of Down syndrome and normal children. It was found that the autistic group played less in both free-play and structured conditions, and that the symbolic quality of the autistic children’s play was significantly poorer than that of controls, lending support to the argument for an impairment in symbolic play in autism. A correlation between the level of symbolic play and verbal MA was observed in the autistic children. In Sigman and Ungerer’s (1984) study, autistic children showed fewer diverse symbolic play-acts than did the controls in both unstructured and structured situations, although symbolic play increased in the structured situation. It was found that the autistic group consistently showed fewer different functional and symbolic play-acts than mentally retarded group and normally developing group (Mundy, Sigman, Ungerer, & Sherman, 1986). The number of symbolic acts performed in the structured situation was also lower for the autistic children in another study in which the children were matched on both mental and verbal abilities (Mundy et al., 1987). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 67 Baron-Cohen (1987) found that among a group of 10 autistic children, compared to the normal and retarded control groups, significantly fewer autistic children produced any spontaneous symbolic play. Only two autistic children demonstrated any pretend play. More recently, Libby, Powell, Messer, and Jordan (1998) observed spontaneous play in children with autism, Down syndrome, and typical development. They found that children with autism had difficulties in the production of symbolic play compared to the other two groups of children. This is especially evident when examining the total number of symbolic play acts produced. Furthermore, the result also indicated that children with autism produced less functional play than the children with typical development. In contrast to the findings above, Lewis and Boucher (1988) studied the 15 autistic children, the control groups of children were having moderate learning difficulties and normal children, and the children were matched for their expressive language abilities. Lewis and Boucher (1988) reported fewer group differences in their study of older and more advanced subjects. In their unstructured situation, very few of the children in any group performed spontaneous symbolic play, a finding that suggests the toys or the situation were inappropriate for this age group. In the structured situation, no group differences were seen, and all the autistic children produced some symbolic play acts by making one object stand for another or imagining absent objects to be present. This study demonstrated that autistics who achieved language abilities compared to those of 5-year-olds, are capable of using Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 68 symbols in play, even though they may not often demonstrate this ability unless required by the task to do so. Similarly, McDonough, Stakmer, Schreibman, and Thompson (1997) found that the children with autism had 24 hours to 3 weeks’ delayed time when they imitated and performed familiar actions of functional and symbolic play. They believed that the autistic children demonstrated more knowledge in the test settings than they demonstrated spontaneously in naturalistic ones, with the possible explanation that the structured test settings might minimize distractions that typically occur in naturalistic settings that may interfere or disrupt symbolic play in children with autism. In sum, studies investigating developmental levels of play have revealed that children with autism are less likely to engage in functional play relative to children with mental retardation or typically developing children (Mundy et al., 1986; Sigman & Ungerer, 1984; Stone et al., 1990). Deficits in functional play have been found to occur in unstructured (Sigman & Ungerer, 1984; Stone et al., 1990) as well as structured settings (Mundy et al, 1986; Sigman & Ungerer, 1984). In addition, functional play skills have been associated with language skills in young autistic children (Sigman & Ungerer, 1984). Deficits in symbolic play also have been observed in children with autism (Mundy et al., 1986; Sigman & Ungerer, 1984), though the results have been less consistent. Symbolic play deficits are more likely to be apparent in structured settings than in unstructured play situations Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 69 (McDonough et al, 1997; Mundy et al, 1986; Sigman & Ungerer, 1984; Stone et al, 1990). However, young children with autism generally have been found to exhibit low levels of symbolic play in experimental situations (Mundy et al, 1986; Stone et al., 1990). Patterns o f Behavior, Interests, and Activities Children with autism may display restricted repetitive and stereotyped patterns of play behavior, and have difficulty establishing meaningful relationships with people and inanimate objects. The deficits of social interaction with people have been discussed already. Parents reporting on the play of children with autism, say that children lacked social engagement and their play was characterized by repetitive and stereotyped object manipulation and nonfunctional use of objects (Mundy et al., 1987; Sigman & Ungerer, 1984; Stone et al., 1990). For example, a toy or an object may interest the autistic children only to the extent that parts of it may be twirled, spun, flicked, tapped, or whirled (DeMyer, Mann, Tilton, & Loew, 1967; Weiner, Ottinger, & Tilton, 1969). Autistic children often form idiosyncratic attachments to objects (Volkmar, Klin, Siegel, & Szatmari, 1994). Young children who are developing normally will often form attachments to transitional objects, typically, soft and cuddly materials that aid them with various transitions. When younger children with autism have attachments to objects, these attachments are often odd: the objects are hard (favorites include cereal boxes, metal cars, or magazines), or the class of object is Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 70 more important than a specific choice (a magazine of a certain type, but not a specific magazine). Thus, in the DSM-IV field trials, attachments to unusual objects were noted of low frequency, but when they were present, they were relatively specific to the diagnosis of autism (Volkmar et al., 1994). Wing (1969) compared the behaviors of 2- to 5-year-old autistic children to those of typically developing children as well as children with mental retardation (MR), receptive or expressive aphasia, or dual sensory impairments. Autistic children exhibited more impaired social relationships and more attachments to objects and routines, relative to all comparison groups. From 50 parents of children with autism, Volkmar, Cohen, and Paul (1986), obtained information about behaviors exhibited by children prior to the age of 6. With regard to restricted and repetitive activities, over 75% of the sample were reported as ignoring toys, demonstrating a preoccupation with spinning objects, and failing to respond to sounds. Unusual habits and patterns were reported for 35% of the sample in Ohta, Nagai, Hara, and Sasaki’s (1987) study about the behaviors exhibited by 48 children with autism between the ages of 4 to 6 years. Lord, Rutter, and Le Couteur (1994) obtained contemporaneous reports of autistic symptomatology for 25 children with autism, and 25 children with MR or language impairments. In contrast to the previous findings, the group did not differ in the stereotyped and repetitive use of language or in the ability to engage in reciprocal conversation. Within the category of restricted activities and interests, the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 71 presence of verbal rituals, unusual sensory behaviors, hand and finger mannerisms, and whole-body mannerisms differentiated the groups. However, repetitive use of objects, presence of compulsions and rituals, and unusual preoccupations were not more common for the children with autism. Consistent with Lord and others (1994), a need for sameness and routines did not differentiate the groups of young children in Stone and Hogan’s (1993) findings from 58 parents of children with autism, and 36 parents o f children with mental retardation. However, in contrast to Lord and others (1994), unusual sensory responses and repetitive motor patterns, were not found to differentiate the groups in Stone and Hogan’s (1993) study. In sum, all studies have reported significant deficits in the areas of social relating and communication, and most have also obtained evidence for the presence of some form of repetitive or restricted activities. However, there is little consistency from one study to another in terms of the specific type of restricted activity evidenced in the autistic samples (Tiegerman & Primavera, 1981). The Use o f Preschool Play Scale (PPS) in Studying the Play o f Children with Autism Restall and Magill-Evans (1994) conducted a study of the play of preschool children with autism. Nine children with autism between the ages of 3 and 6 years who were matched with nine normally developing children for their gender, age, and parental socioeconomic status were included in this study. The Preschool Play Scale Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 72 (PPS) and the Vineland Adaptive Behavior Scales (VABS) were administered, and the types of play materials chosen were recorded. Significant differences were found between the two groups on the total PPS score and on the participation dimension, whereas no differences existed between groups on the play materials chosen and on the other dimensions of PPS. The results were consistent with the previous research in suggesting that autistic children have deficits in the amount of and the manner of social interaction during play (Restall & Magill-Evans, 1994). In contrast to the previous arguments about autistic children’s abnormal functioning in social imitative or symbolic play, or restricted, repetitive, and stereotyped patterns of behaviors, interests, and activities, the findings of this study have revealed that autistic children performed with no significant differences as compared to normally developing children in the dimensions of PPS (i.e., space management, material management, and imitation/pretense/symbolic) and types of play materials chosen (Restall & Magill-Evans, 1994). Restall and Magill-Evans (1994) discussed their impression that the observation methods used in administering the PPS, made it difficult to detect a broad range of motor skills, especially with children in the older age. They proposed that this might have resulted in the lack of difference between groups on the space management dimension. They also provided two possible explanations on the lack of differences between groups on the imitation dimension. First, the lower power of statistical test (due to the small sample size), is one possible explanation for the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 73 nonsignificant findings. Second, the lack of imitative and imaginative play observed with children with autism, may be related to social learning rather than a unique feature of the disorder. Finally, three important areas of future research were suggested by Restall and Magill-Evans (1994) as follows: (a) to investigate differences in play performance among home, preschool settings, and clinic settings; (b) to examine the relationships between play performance in this age group and long-term outcomes; and (c) to examine the relationships between preschool play performance and future adaptive abilities. Conclusion A number of researchers have indicated that individuals with autism demonstrated deficits in play behavior in three major areas. First, there are qualitative impairments in social interaction during play. Second, there is a lack of varied spontaneous social imitative, functional, or symbolic play. Finally, restricted repetitive and stereotyped patterns of behaviors, interests, and activities are observed. Although the play performance of children with autism has been influenced by their developmental deficits, a wealth of studies have confirmed the increase in play behavior of children with autism when prompting procedures (Charman & Baron-Cohen, 1997; Jorrold, Boucher, & Smith, 1996; Lewis & Boucher, 1988), modeling and reinforcement (Charlop, Schreibman, & Tryon, 1983; Egel, Richman, & Koegel, 1981; Tryon & Keane, 1986), instruction, guidance, prompting /modeling/reinforcement (Meyer et al., 1987; Wolfberg & Schuler, 1993; Stahmer & Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 74 Schreibman, 1992), self-management techniques (Stahmer & Schreibman, 1992), self-stimulation techniques (Koegel, Firestone, Kramme, & Dunlap, 1974) and imitation (Libby et al., 1997; Tiegerman & Primavera, 1981) were provided. "Theory o f M ind” Deficit in Autism In order to better understand the autistic children’s performance in domains associated with social functioning, it is vital to mention a crucial area of research that has generated a considerable amount of attention. Drawing from evidence and work in this area of research, it is generally believed that a theory of mind deficit in autism provides adequate explanation about the triad of impairment in sociability, communication, and symbolic imagination seen in children with autism (Baron- Cohen, 1995). The term “theory of mind” was originally phrased by Premack and Woodruff (1978). They suggested that the ability presented in theory of mind reflects unobservable entities of mental states underlying people’s actions. This ability also has the properties of a theory to explain and to predict people’s behavior that leads to the theory-like characteristic of this ability (Premack & Woodruff, 1978). A “theory of mind” is defined as the ability to infer one’s own and other people’s mental states (e.g., thoughts, beliefs, desires, intentions, knowledge, pretense, and perception), and the ability to link, to make sense, to interpret, and to predict people’s actions and behaviors (Baron-Cohen, 1995; Baron-Cohen, Tager- Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 75 Flusberg, & Cohen, 1993). Indeed, a term of “mind-reading” might be more understandable to represent this ability (Baron-Cohen, 1995). A considerable amount of research has shown that children with autism have particular difficulties in reasoning about one’s own and others’ mental states. Children with autism also exhibit many developmental abnormalities that are unique and associate with autism. Children with autism can be conceptualized as having degrees of mind blindness (Baron-Cohen, 1995). The characteristics synthesized below, might help to understand what particular parts of daily living function are impaired in children with autism associated with their mind blindness. A number of experiments provide strong evidence for being a theory of mind deficit in autism. It is generally agreed that the children with autism, to some degree, have difficulty understanding how physical objects differ from thoughts about objects {mental-physical distinction) (Baron-Cohen, 1989). Also, children with autism fail to make the appearance-reality distinction, inability to distinguish what the object looks like and what they know it really is (Baron-Cohen, 1989). Hence, children with autism are unable to make the accidental-intentional distinction, that is, the inability to distinguish whether people are meant to do something, or whether it simply happened accidentally (Phillips, 1993). In addition, children with autism have problems with understanding the m ind’ s mental function in the status of thinking, dreaming, wishing, and deceiving (Baron-Cohen, 1989). Children with autism demonstrate confusion in situations Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 76 involving false belief a complex ability, because they have to take into account another person’s belief in order to make the correct prediction about his/her behavior (Leekam & Pemer, 1991; Swettenham, 1996). Subsequently, it is hard for children with autism to understand the principle of “seeing-leads-to-knowing” (Leslie & Frith, 1988). For example, children at 3 to 4 years of age can easily indicate or judge who of the two people will know what is in a box— if one of them has looked into the box- -whereas the other has only simply touched the box. This ability is important to demonstrate the children’s awareness of the significance of access to information to actually acquire knowledge (Baron-Cohen & Goodhart, 1994). More importantly, children with autism have difficulty recognizing the eye- region o f the face as an indicative gesture, showing when a person is thinking and what a person might want (Baron-Cohen, Campbell, Karmiloff-Smith, Grant, & Walker, 1995). Children with autism also have difficulty in recognizing mental state words such as think, know, or imagine (Baron-Cohen, Ring, Mori arty, Shmitz, Costa, & Ell, 1994); and of course, they rarely produce this kind of mental state words in their spontaneous speech (Tager-Flusberg, 1993). Similarly, impaired understanding of the mental state of pretending has been found, and apparently, the lack of the production of spontaneous pretend play has been anticipated (Lewis & Boucher, 1988). Not surprisingly, it would be too difficult for children with autism to have an appropriate understanding of complex causes o f emotion, desire, belief and empathy (Baron-Cohen, Spitz, & Cross, 1993). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 77 Interestingly, children with autism have the inability to deceive or understand deception that is all about making someone believe that something is true when it is actually false (Sodian & Frith, 1992). Therefore, they cannot understand that people’s thoughts, beliefs, what they know, and how they think can be shaped and changed through persuasion. Evidently, it seems difficult for children with autism to comprehend such intentionally nonliteral statements as metaphor, sarcasm, and irony (Happe, 1994); and simultaneously, to produce appropriate pragmatics in their speech (Tager-Flusberg, 1993). In sum, there is considerable evidence for being a theory-of-mind deficit in population with autism. Children with autism might be impaired in the development of theory-of-mind and the deficit makes it difficult for them to represent and to appreciate the mental states of themselves and others. Being a theory-of-mind deficit signifies to explain the social, communicative, and imaginative abnormalities that have been seen in persons with autism. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 78 CHAPTER III M ETHODOLOGY Introduction It was the purpose of this study to compare the play of boys with autism, with boys without disabilities as it occurred within free-play contexts with naturalistic observation and administration of standardized instruments. This chapter will describe the methods and procedures used in the study. It will be organized in the following sections: (a) description of the conceptual assumption/framework for the study; (b) selection of the participants; (c) description of the instrumentation; (d) description of the research procedures: preparatory phase, pilot study and focused phase; (e) description of the data recording; (f) description of the data processing; and (g) description of the plan for data analysis. Conceptual Framework fort the Study This study was operated on the following conceptual assumptions: 1. Play is a significant occupation of the child (Alessandrini, 1949; Ferland, 1997; Kielhofner, 1985, 1995; Reilly, 1974). 2. Play is a developmental and mastery process in childhood (Johnson et al., 1999; Reilly, 1974). 3. Children develop through stages in motor, psychological, and social areas (Johnson et al., 1999; Knox, 1968, 1974, 1997). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 79 4. Play not only contributes to the children’s development in all areas, but also reflects their developmental stages as well (Johnson et a l, 1999; Knox, 1968, 1974, 1997). 5. An observation is particularly appropriate for the study of play behavior because it can capture the complexity and richness of this phenomenon (Knox, 1974, 1997). 6. Performances of the children during observation sessions in a naturalistic environment reflect their actual play abilities (Knox, 1974, 1997). Participants Since autism is not commonly diagnosed until the age of 3 years and subjects who are 3 to 5 years, represent an important age period to assess play; children who are 3 years to 5 years, were enrolled for the present research. Only boys were enrolled in the study, not only to control for the possibility o f sex-related differences on play performance, but because of the higher prevalence of autism in males. Generally, research has yielded prevalence estimates at least two to five times as high for males as those reported in females (APA, 1987, 1994). The detail criteria for subjects’ inclusion and exclusion will be described below. Inclusion Criteria All subjects for this study were recruited from the urban area of Tainan City. The subject’s primary language is Mandarin/Chinese. In Taiwan, once the parents are suspicious about any problems the child has, they visit the clinicians in the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 80 general hospital for farther identification or clarification. Clinicians in Taiwan use Diagnostic and Statistical Manual o f Mental Disorders (DSM) as the most recent and most extensively evaluated diagnostic guide for autism. In this study, boys with autism were referred to as boys who received a psychiatric diagnosis of autistic disorder based on the criteria for diagnosis set forth in D SM IV (APA, 1994), and were diagnosed by the special interdisciplinary team of clinicians in the general hospital. The autistic samples were recruited from the diagnostic center for children with developmental delay in a hospital of a university in Tainan. As part of the preparation for this research, the principal investigator visited the director and clinicians of this center. Their cooperation and support had been earned for the provision of the prospective participants. The introductory brochure, the inclusion and exclusion criteria for subject recruitment were also given to the director, the committee, and the colleagues of this diagnostic center as their reference for the provision of the prospective participants. The control group of boys without disabilities consisted of normally developing boys without disabilities, who were recruited from a day-care center/kindergarten in Tainan. The child’s normal development was judged by his parent in several screening questions that indicated that the child demonstrated no psychiatric, psychological, physiological, or neurological problems. Additionally, the child received no special therapeutic services at the time, and was not taking prescription medications (e.g., for hyperactivity, seizures). These screening Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 81 questions had been converted to Mandarin/Chinese, and evaluated using a back translation procedure to ensure the accurate translation of the content. Exclusion Criteria For both groups, children with symptoms associated with organic brain dysfunction (e.g., seizures), orthopedic problems, hearing loss, or gross visual deficits were excluded. Sample Size Seventy-nine children participated in the present research: 37 with autism and 42 without disabilities. The power analysis was used to determine the sample size needed in this study to increase the likelihood of demonstrating significant results if differences truly exist (Table 1). In this study, the power analysis was computed to answer the question of how large a sample was needed for this study, given a significance criterion of .05 and power equal to .80. In performing a power analysis, evidence and data came from Restall and Magill-Evans’ (1994) study on a similar problem were used in the procedure to estimate the magnitude of the effect size. Followed by the results of power analysis, 30 subjects per group, at least, were estimated and were needed in the study. Thus, 30 boys without disabilities and 30 boys with autism were needed; and 10 boys each with autism and without disabilities, were needed to be recruited for each age groups of 3-, 4-, and 5-year- olds. Since the observations of each child were expected to be conducted within a Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 82 month, the child’s age in the group of 3-year-olds were 3 years 0 month to 3 years 11 months when the first observation occurs. The same rale was executed for the recruitment of subjects in the groups of 4- and 5-year-old. T a b l e 1: A p p r o x i m a t e S a m p l e S i z e N e c e s s a r y t o A c h i e v e S e l e c t e d L e v e l s o f P o w e r a s a F u n c t i o n o f E s t i m a t e d E f f e c t S i z e f o r T e s t o f D i f f e r e n c e o f T w o M e a n s T o t a l P P S P a r t i c i p a t i o n S p a c e M a t e r i a l M a n a g e m e n t M a n a g e m e n t T e s t s i g n i f i c a n c e le v e l 0 . 0 5 0 0 . 0 5 0 0 . 0 5 0 0 . 0 5 0 1 o r 2 s i d e d t e s t ? 2 2 2 2 G r o u p ( a u t i s m ) m e a n 3 3 . 5 7 0 2 7 . 3 3 0 2 4 . 0 0 0 3 8 . 9 3 0 G r o u p ( N o n - a u t i s m ) m e a n 4 2 . 5 3 0 4 4 . 0 0 0 3 6 . 0 0 0 4 6 . 1 3 0 D i f f e r e n c e i n m e a n s - 8 . 9 6 0 - 1 6 . 6 7 0 - 1 2 . 0 0 0 - 7 . 2 0 0 C o m m o n S D 6 . 5 5 0 1 2 . 3 7 0 1 5 . 8 8 0 8 . 4 7 0 E f f e c t s i z e 1 .3 6 8 1 .3 4 8 0 . 7 5 6 0 . 8 5 0 P o w e r ( % ) 8 0 8 0 8 0 8 0 N p e r g r o u p 1 0 1 0 2 9 2 3 Instrumentation Revised Knox Preschool Play Scale The Play Scale was developed in 1968 by Susan Knox. The Play Scale was revised and renamed as the Preschool Play Scale (PPS) by Bledsoe and Shepherd (1982) for three major reasons: (a) to make all items mutually exclusive, (b) to maintain consistency between categories and age levels, and (c) to update the scale to reflect recent developmental studies on play. In the present study, the Revised Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 83 Knox Preschool Play Scale (PPS) was administered to measure play performance in a developmental framework (Knox, 1974, 1997). The scale was an adaptation of an observation model originally postulated by Erik Erikson (Knox, 1974). According to Knox (1974), the play scale was constructed on the basis of descriptions of normal play behaviors as shown by many play theorists. Four divisions were postulated which met the criteria for dimensions of scales: (a) observability, (b) measurability, (c) definability, and (c) literature consensus (Knox, 1974). An overview of the PPS will be described below. The PPS is a structured observational checklist to provide a developmental description of typical play behavior through the ages 0 to 6 years (Appendix C). The PPS involves the researcher’s naturalistic observation of the children’s free play. The PPS scoring sheet have a section that allow the researcher put down any information that he/she interests in (Appendix D). The scale yields an overall play-age score (in months) derived from an averaging of the child’s scores from four dimensions of play (Space Management, Material Management, Pretense/Symbolic, and Participation). The four dimensions of PPS coincide approximately with the areas of division of play behavior shown by the play theorists including active physical play, manipulative-constructive play, imitative-imaginative-dramatic play, and social play (Knox, 1968). Within each dimension, two to four categories of play behavior are described, with a total of 12 categories counted in PPS. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 84 Space Management refers to the way a child manages his/her body, and the space around him/her through the processes of experimentation and exploration (Knox, 1997). It includes the category of gross motor activity and interest. The bases for the repertoire of activity are the basic postural mechanisms (lying, sitting, walking, etc.), and progresses in the following manner: (a) experimentation with what his own body is capable of doing through gross physical activity; (b) exploration of immediate space and time through expansion of bodily activity; and (c) exploration of space outside the limits of immediate time and space through remembrance of past events ad anticipation of future events (Knox, 1974). Material Management refers to the manner in which a child handles material surroundings (Knox, 1997). It consists of the category of manipulation, construction, purpose, and attention. It includes ways in which the child learns control and uses the surrounding material. The progression of material management is as follows: (a) exploration of self and objects through oral and tactical senses with the emphasis on the sensation itself; (b) expansion of the tactical senses through manipulation and construction, the emphasis being on process; (c) refinement of skills through fine manipulation and construction with emphasis on the result; and (d) emphasis on reasoning and the permanence of products (Knox, 1974). Pretense/Symbolic refers to “the way a child learns about the world through imitation and the development of the ability to understand and separate reality from make-believe” (Knox, 1997, p. 50). It contains the category of imitation and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 85 dramatization. It includes mimicking the actions and speech of others, imitation of present, past and anticipated future events, and dramatization of events and feelings. Through imitation, the child learns control of self and expands this understanding to balancing the control between the self and the environment (Knox, 1974). Participation refers to the amount and manner of interaction with people in the environment and the degree of independence and cooperation demonstrated in play activities, and it includes the category of type, cooperation, humor, and language in play (Knox, 1997). Participation develops in the following manner: (a) egocentricity and attention demand; (b) interaction with one person, the mother figure; (c) interest in others, primarily through observation; (d) association but not true interaction with peers; and (e) cooperation and true interaction with others (Knox, 1974). Utilizing the previously described levels and dimensions of play, the scale is constructed in 6-month increments up until 3 years and in yearly increments from 3 to 6 years of age, across the horizontal axis, and running the four dimensions up the vertical axis. The body of the graph contains descriptions of play behavior during these intervals. Reliability and validity studies have provided evidence of acceptable test- retest and inter-rater reliability as well as of concurrent validity of the PPS for the population with normal development (Bledsoe & Shepherd, 1982), and children with disabilities including cerebral palsy, mental retardation, and developmental delay Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 86 (Harrison & Kielhofner, 1986). In addition, since its development and revision, the PPS has been used widely with different categories of children, including children who have been hospitalized for prolonged periods (Kielhofner et a l, 1983), physically abused individuals (Howard, 1986), preschoolers with sensory integrative dysfunction (Bundy, 1989; Clifford & Bundy, 1989), children with juvenile rheumatoid arthritis (JRA) (Morrison, Bundy, & Fisher, 1991), and preschool children with autism (Restall & Magill-Evans, 1994). Reliability. Bledsoe and Shepherd’s (1982) collected normative data on 90 children ranging in age from 4 months to 6 years and conducted reliability and validity studies. Play behavior of each subject was observed and rated for three 30- minute sessions over a period of 7 days including concurrent ratings of the PPS by two independent raters, and an additional rating on the PPS by a single rater. Data were analyzed statistically. Inter-rater and test-retest reliability for the entire sample was computed for each category, each dimension, and the play age score of the PPS. The results indicated that correlation between two raters (inter-rater reliability) ranged from .98 for the four dimensions to .996 for the total play age score, and correlation coefficients ranged from .89 to .93 between the two raters for category scores. This suggests that two trained raters could objectively assess the play behavior of a child and obtain essentially the same developmental level. Test- retest reliability coefficients for dimension and play age scores with the same rater and with different raters ranged from .85 to .97. Correlation for category scores by Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 87 the same rater and by different raters ranged from .67 to .91. This significant stability coefficients for dimension and play age scores suggest that, although specific types of play may vary, the overall level of play should be stable across an interval of 1 week or less. Validity. Bledsoe and Shepherd (1982) found that all categories of PPS correlated significantly with chronological age, with correlation coefficients ranging from .65 to .85, which suggest that PPS behavioral descriptions do reflect sequential play development. The significant correlation between the PPS and Parten’s Social Play Hierarchy scores, with correlation ranging from 60 to .62, support that the PPS is a credible tool for assessing developmental social play behavior. The significant correlation between the scores on the PPS and the scores obtained using Lunzer’s Scale of Organization of Play Behavior, with correlation ranging from .58 to .71, can be interpreted as support for the PPS’s ability to evaluate the physical and cognitive aspects of play. In sum, concurrent validity results suggest that the PPS does measure play on a developmental continuum of increasing complexity including physical, cognitive, and social components. Reliability and validity o f PPS with handicapped children. Harrison and Kielhofner (1986) examined the reliability and validity of the PPS on a sample of 60 children with disabilities whose ages ranged from 2 months to 5 years and 11 months. Each subject’s primary disability was classified according to the following categories; cerebral palsy, mental retardation, developmental delay, or other. Data Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 88 were collected by observing the free play of each child for two 15-minute observation sessions, with an interval of 4 to 14 days between the first and second session. All sessions were conducted indoors and at the same time of day. Inter-rater reliability with the PPS was examined using a subsample of 15 subjects and three independent raters who simultaneously observed and rated each child. Test-retest reliability of the PPS and concurrent validity was examined using the entire sample of 60 subjects. Results showed that correlation among three raters (inter-rater reliability) ranged from .55 to .88 for the four dimensions, and .88 for the total play age score. Correlation coefficients ranged from .70 to .91 for category scores. Test-retest reliability coefficients for dimension and play age scores with the same rater ranged from .73 to .91. Correlation for category scores by the same rater and by different raters ranged from .62 to .97. The significant correlation between the PPS and Parten’s Social Play Hierarchy scores, with correlations ranging from .60 to .64, support that the PPS is a credible tool for assessing developmental social play behavior. The significant correlation between the scores on the PPS and the scores obtained using Lunzer’ z Scale of Organization of Play Behavior, with correlation ranging from .50 to .89, can be interpreted as support for the PPS’s ability to evaluate the physical and cognitive aspects of play. In sum, the data from Harrison and Kielhofner’s (1986) study, generally demonstrated acceptable reliability and validity for the PPS as a whole, and suggested that the PPS detects play delays in children with disabilities. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 89 Peabody Picture Vocabulary Test-Revised (PPVT-R) The Peabody Picture Vocabulary Test-Revised (PPVT-R) (Dunn & Dunn, 1981) was originally developed in 1959 and was revised in 1981. It is a nonverbal, multiple-choice test designed to evaluate the hearing vocabulary or receptive knowledge of vocabulary of children and adults. It covers individuals from age 3 years through adulthood. The test is untimed and requires no reading ability. The physical abilities required of examinees are adequate hearing and the ability to indicate yes or no in some manner. Neither a pointing nor an oral response is essential. Testing time is between 10 and 15 minutes. O f the 300 items in the 1959 edition, 144 are included in the 1981 edition. Item analysis procedures were used to select new items for the revision. Words were selected so as to include a relatively good balance of nouns, gerunds, and modifiers in 19 content categories. Items favoring one sex were eliminated entirely or counter balanced by adding items favoring the opposite sex. Words from the earlier edition that were found to be culturally, regionally, or racially biased were not included in the revision. The PPVT-R has two forms, L and M, with five examples and 175 plates in each form. Each plate contains four pictures. Items are arranged in increasing levels of difficulty. The two forms use different words and pictures. The pictures are clearly drawn, free of fine detail, and pose no figure-ground problems. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 90 Chinese Version of Peabody Picture Vocabulary Test-Revised (Chinese Version o f PPVT-R) The PPVT-R was further revised, translated into the Chinese version, and published by Lu and Liu in 1994 for the use in the Taiwanese population. Items analysis procedures and data from the pilot test on 656 subjects, with 353 males and 303 females, from age 3 years through 12 years, were used to revise the items for the Chinese version. After the elimination of the words that were found to be culturally biased, having ambiguous meaning, or were difficult to translate properly, the Chinese Version o f Peabody Picture Vocabulary Test-Revised has two forms, L and M, with five examples and 125 plates in each form (Lu & Liu, 1998). As is case with the PPVT-R, each plate contains four pictures. Items were arranged in increasing levels of difficulty. The two forms used different words and pictures. The pictures were clearly drawn, free of fine detail, and posed no figure- ground problems. Raw scores are then converted into standard scores, with a mean of 100 and standard deviation of 15, in proper age population, ranging from 55 to 145. Further, the standard scores were converted into the percentile rank. Standardization o f the Chinese Version o f PPVT-R (Lu & Liu, 1998). The normative group was a representative national sample of 886 youths, ages 3 years through 12 years, based on the 1985 Taiwan census data. These children, with 454 males and 432 females, approximately equal divided by sex, were included within each of 14 age groups. These groups were at half-year intervals for ages 3-0 through Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 91 6-11 years and at 1-year intervals for ages 7 through 12 years. The sample was stratified by sex, geographic region, occupation of major wage earner, and community size. Reliability o f the Chinese Version o f PPVT-R (Lu & Liu, 1998). Split-half reliability coefficients range from .90 to .97 (Mdn r - .95) on Form L. On Form M, they ranged from .90 to .97 {Mdn r = .96). The median standard error of measurement for the standard scores is 3.70 for Form L, and 3.66 for Form M. Test- retest reliability coefficient is .90 on Form L, and .84 on Form M. Altemate-form reliabilities for all samples given Form L then Form M ranged from .60 to .91 {Mdn r = .79). Validity o f the Chinese Version o f PPVT-R (Lu & Liu, 1998). In a sample of 23 children for group aged 8 years, correlation coefficients between the Chinese Version o f PPVT-R: Form L and the WISC-R Verbal Scale IQ is .60, and the WISC- R Non-verbal Scale IQ is .44, and the WISC-R Full Scale IQ is .61, and the WISC-R Vocabulary Subtest Score is .55. Correlation coefficients between the Chinese Version o f PPVT-R: Form M and the WISC-R Verbal Scale IQ is .60, and the WISC- R Nonverbal Scale IQ is .62, and the WISC-R Full Scale IQ is ,69, and the WISC-R Vocabulary Subtest Score is .48. In a sample of 90 children, 30 each for groups aged 6 years, 8 years, and 10 years; correlation coefficients between the Chinese Version o f PPVT-R and Goodenough-Harris Drawing Test is .34, .41, and .19 on Form L; whereas .44, .36, and .22 on Form M. According to the conclusion of the user Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 92 manual (Lu & Liu, 1998), these correlations established the concurrent validity of the Chinese Version o f PPVT-R as a measure of cognitive ability. Research Procedures The study was conducted in three phases: (a) the preparatory phase, (b) the pilot study, and (c) the focused phase, over a time period of approximately 10 months. This section will present the purposes for each phase. Preparatory Phase The preparatory phase of the study emphasized the preparation and the enhancement of the researchers’ qualifications in data collection, data processing, and data management. In the present study, one principal investigator was in charge of all the research progress, and several research assistants were needed to operate the videotaping equipment throughout the period of data collection. In order to gain adequate videotaped observational data, training of the principal investigator and research assistants became crucial factors. The training was conducted to enable the principal investigator to develop skills at appropriately administering the instruments, and to enable the research assistants to develop adequate skills at videotaping. Description o f training fo r principal investigator. The principal investigator received a preliminary observational training before the actual data collection for the purpose of becoming familiar, reliable, and qualified with the use of the instrument (i.e., observe, record, and rate information accurately). The principal investigator Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 93 was trained to score and to administer the instrument from Susan Knox, a Ph.D. who developed the PPS, and with another trained/experienced occupational therapist, who was familiar with the administration of PPS. In the first training session, the principal investigator explored the nature/content, the behavioral descriptions, the scoring system, and the procedures of administration of the PPS with Susan Knox’s demonstration. During this session, videotapes of several children’s play were viewed, reviewed, discussed, and rated. Any clarifications or questions of judgments were discussed. In the second session, six videotapes of free-play behavior of children aged 3 to 5 years were showed, independently rated by three observers, and then discussed. Inter-rater reliability was established among the principal investigator, Dr. Susan Knox, and an experienced pediatric occupational therapist, that point-by-point agreement reached over 80%. At the end of this training phase, the principal investigator was capable of administering the instrument in standardized procedures with high confidence and reliability. Description o f training fo r research assistants. In the present study, several research assistants were needed to operate the video camera. Prior to collecting study data, several research assistants were trained and were instructed to correctly use the videotaping equipment and to structure the videotaping session in the least disruptive manner. A mock videotape was conducted by the principal investigator, and then was shown to the research assistants to demonstrate an acceptable quality of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 94 recorded data. Several videotaping procedures and techniques were clearly instructed to ensure successful recording and to obtain high-quality data. For example, an adequate size of the field of view (the area to be shown on videotape), an expected distance between the camera and subject, an appropriate lighting strategically placed and operating the camera, were clearly demonstrated and were fully instructed. More detailed information and procedures associated with videotaping in natural settings used in the study, will be described in the section of focused observation and videotaping. Pilot Study A pilot study often involves a small-scale test of the entire study, that is, a testing of not only instruments but also the sampling plan, the intervention, and the study procedures (Polit & Hungler, 1995). For the present research, the administration and applicability of the instrument, the methods of data collection, and the entire study procedures were pilot-tested with two Taiwanese boys, ages 3-5 years, one with normal development and one with autism. The pilot data were summarized at Table 2. Purposes o f the pilot study. The purposes of the pilot study were threefold: (a) to test the adequacy of the study procedures to find out the use and the applicability of PPS (Revised Preschool Play Scale) with Taiwanese population, and to test the appropriateness of the screening questions for child’s normalcy; (b) to identify the problems of study design or any parts of the data collection procedures that the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 95 T a b l e 2 : P i l o t D a t a B o y w i t h a u t i s m B o y w i t h o u t d i s a b i l i t i e s C h r o n o l o g i c a l A g e 4 y e a r s 8 m o n t h s 4 y e a r s 7 m o n t h s P P V T - R R a w S c o r e 1 9 5 9 C o n v e r t e d S t a n d a r d S c o r e 8 6 1 2 2 C o n v e r t e d P e r c e n t i l e R a n k 1 8 9 3 P P S S p a c e M a n a g e m e n t G r o s s M o t o r 6 0 - m o n t h 6 0 - m o n t h I n t e r e s t 1 8 - m o n t h 4 8 - m o n t h ( M e a n ) 3 9 - m o n t h 5 4 - m o n t h M a t e r i a l M a n a g e m e n t M a n i p u l a t i o n 3 0 - m o n t h 6 0 - m o n t h C o n s t r u c t i o n 1 8 - m o n t h 4 8 - m o n t h P u r p o s e 0 6 - m o n t h 4 8 - m o n t h A t t e n t i o n 7 2 - m o n t h 7 2 - m o n t h ( M e a n ) 3 2 - m o n t h 5 7 - m o n t h P r e t e n s e / S y m b o l i c I m i t a t i o n 1 2 - m o n t h 6 0 - m o n t h D r a m a t i z a t i o n 1 2 - m o n t h 6 0 - m o n t h ( M e a n ) 1 2 - m o n t h 6 0 - m o n t h P a r t i c i p a t i o n T y p e 0 6 - m o n t h 4 8 - m o n t h C o o p e r a t i o n 1 2 - m o n t h 4 8 - m o n t h H u m o r 1 2 - m o n t h 3 0 - m o n t h L a n g u a g e 1 2 - m o n t h 4 8 - m o n t h ( M e a n ) 1 0 . 5 - m o n t h 4 3 . 5 - m o n t h P l a y A g e / M e a n o f A l l D i m e n s i o n s 2 3 . 3 8 - m o n t h 5 3 . 6 3 - m o n t h Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 96 participants find objectionable or offensive, and (c) to allow the researcher and assistants to practice the procedures and needed techniques (e.g., recording field notes, videotaping). With the execution of designed procedures for subject recruitment, the principal investigator obtained several potential participants’ contact information. Two subjects were randomly chosen to be enrolled in the pilot study. The free play behaviors of subjects were observed twice, once indoors and once outdoors, in their daily routine schedule at the day care center for the subject with autism, and at the kindergarten for the subject without disabilities. The Chinese Version o f PPVT-R was also administered on both of them. Conclusions o f the pilot study. In general, several conclusions can be made from the experience of conducting the pilot study with two subjects. First, with the sincere attitude, well-prepared documentation, and the detailed explanation of the nature of the study, the principal investigator had no difficulty obtaining parental consent of the subject’s participation. Second, the parents demonstrated no difficulty filling out the needed documentation (i.e., consent form and demographic information) in 5-10 minutes, and adequately answered the screening questions for the subject’s normalcy (only for parents of normally developing subject) as well. Third, two research assistants were trained and were instructed to correctly use the videotaping equipment and structure the videotaping session in the least disruptive manner. With the principal researcher’s satisfaction, research assistants both demonstrated the acceptable quality of videotaping skills, the principal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 97 researcher had high confidence on successfully recording field notes in the settings as well. Fourth, all study procedures were smoothly connected and the adequacy of the study design were ensured. Changes research design based on pilot study. Several problems were identified that the researcher needed to address. In the pilot study, the first identifiable problem was that the parents of the subject with autism had offensive and irritable reactions on having their child be videotaped. However, they became comfortable after a long conversation involving the researcher’s reassurance of the complete confidentiality. Thereby, for the actual data collection, a focused conversation on the choice of videotaped observation as the preferred method of data collection was well-prepared, and was given to parents of potential participants at the first meeting. The second identified problem was that the principal investigator faced an extreme challenge to successfully administer the Chinese Version o f PPVT-R test on the subject with autism without the supervising adult’s assistance. In the pilot study, with the mother’s assistance, the autistic subject took about 40 minutes to finish the Chinese Version o f PPVT-R test, whereas the normal subject finished the test independently in 5 minutes. During the test administration, the autistic subject showed no interest, paid no attention on the test, and demonstrated severe difficulty following the researcher’s instruction. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 98 Speaking from the pilot-tested experience, the companionship of people whom the subjects trusted was the most significant enforcer for this encounter. In the pilot study, the mother of the subject with autism made the crucial contribution of pulling the subject’s attention back on the task, and on seating the subject appropriately to complete the whole test. Derived from the experience in the pilot study, for the actual data collection, the companionship and assistance of the supervising adults were requested and arranged, in the period of test administration on subjects with autism, to ensure their optimal cooperation. Additionally, the considerable amount of time that subjects with autism would take to complete the test was anticipated and was scheduled in the actual data collection. The third identified problem was the communication with the coordinators/teachers at observational settings. Theoretically, subjects might be observed at the nursery, at the home of the subject, or in preschool settings, depending on what is most convenient or appropriate. In the pilot study, the researcher followed the proposed procedures to set up the time and place with parents, for play observations of the subject. The preschool setting was chosen, and a certain time was scheduled to observe the free play of the subjects with autism in the familiar environment with peers present. In the pilot study, the coordinator of the preschool setting where the autistic subject was currently enrolled, requested an oral presentation made by the principal investigator, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 99 for the consideration of giving the approval to the researcher to conduct the study in this setting. For the actual data collection, the brief presentation and detailed explanations regarding the research were well-prepared, and the principal investigator was ready to give the presentation anytime when needed. Some issues needed to be specially addressed and recognized by teachers. The researcher and research assistants observed and videotaped the subject’s performance as unobtrusively as possible, and were nonparticipants throughout whole period. The last identified problem was the communication with other children at observational settings. In the pilot study, subjects were observed in the preschool setting (subject with autism) and kindergarten (subject without disabilities) where numerous children were around. There were lots of interest in the researchers’ presence and that of the video camera. It was also common that some children would wander over to the researchers, ask questions, talk about things, show off, or try to obtain the researchers’ attention in a number of ways. Derived from the pilot-tested experience, two issues were addressed and adjusted for the actual data collection. First, teachers were asked to formally explain to the children, in the ways they understood, about the researchers’ presence, and the expected cooperation of leaving the researchers as unobtrusively as possible throughout whole period. Second, the longer warm up sessions were arranged and scheduled to decrease the children’s curiosity and comfort their anxiety. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 100 In the pilot study, the entire study procedures and design were tested and were found to be smoothly connected and adequately executable. Several problems were identified, whereas some modifications and strategies were described and used to refine the actual data collection. Focused Phase The focused phase addressed the research questions of the study and several procedures will be described in sequence in when they occurred, that is (a) procedures of subjects recruitment, (b) obtain parental consent, and (c) focused observation and videotaping. Procedures fo r subject recruitment. The general criteria (age, sex, and diagnosis) for a certain child and the introductory brochure were given to the clinicians (for the group of autistic boys) and teachers (for the group of normal boys) as their reference. The introductory brochure contained brief information regarding the research and the answers to some commonly asked questions. The introductory brochure had been converted to Mandarin/Chinese and evaluated using a back translation procedure to ensure the accurate translation o f the content (Appendix E). For subject recruitment, the principal investigator met and stayed in frequent contact with the clinicians who worked in the hospital of the university in Tainan, and the teachers who worked in the day-care center/kindergarten in Tainan. The sample of boys with autism consisted of the boys who currently visited this hospital for services at the time or the boys who had been seen in this hospital during the last Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 101 2 years, who were likely to meet the eligibility criteria based upon clinicians’ documentation. The samples of normal subjects were the current students at the time in the day-care center/kindergarten in Tainan. With respect to privacy of the potential subjects prior to their consent, the investigator had no information of the potential participants, and surely made no contact with the potential participant’s parents initially. Instead, the clinicians or teachers of the potential participants, who already had rapport with the parents, made initial contact with potential participants parents by phone, by mail, or in person, as part of the regular follow-up process (clinicians vs. patients) or as the daily routines (teachers vs. students), to introduce the investigator, and to ask if these parents were willing to share their phone number with the investigator. Some potential participant’s parents asked for and reviewed the introductory brochure before giving their permission to share their phone number with the investigator. If they showed no interest in participating, their contact information was not released to the investigator. At the time the investigator received the contact list of phone numbers, the investigator then contacted the parents to arrange a face- to-face visit in order to explain the study, to elicit their support, and to ask for parental consent of subject’s participation. Obtain parental consent. The principal investigator received the contact list of the prospective participants, and then contacted these caregivers or parents to explain the nature and the extent of the study, to elicit their support, and to ask for Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 102 parental consent of the subject’s participation. In this phone contact, the investigator briefly explained the nature of study and asked the screening questions (only for parents of normally developing children) (Appendix F), explained the eligibility criteria for subjects’ inclusion and exclusion, and presented the videotaped observation as the preferred method of data collection. When the child met the inclusion criteria and the parent showed interest in participating, the investigator made an appointment to visit the parent and the child at the location of their preference, and at a time that was convenient for their family. The investigator fully explained the nature/ procedures of the study and the content of the informed consent to those parents of the prospective subjects, and further asked their consent to allow their child to participate. During this visit, the content of the informed consent was fully explained and reviewed. The written informed consent consisted of information as follows: (a) a statement of the purposes of the research; (b) the expected duration of the subject’s participation; (c) a description of the procedures were followed; (d) a description of any reasonable foreseeable risks or discomforts to the subject; (e) a description of any benefits to the subject, or to others, which were reasonably expected from the research; (f) a statement describing the extent to which confidentiality of records identifying the subject were maintained and were reassured; (g) an explanation of whom the content for answers were to pertinent questions about the research and research subjects’ rights; and (h) a statement that participation was voluntary, refusal Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 103 to participate involved no penalty and the subject might discontinue participation at any time without penalty. The written informed consent had been converted to Mandarin/Chinese, and evaluated using a back translation procedure to ensure the accurate translation of the content (Appendix G). Parents were told that the investigator wanted to learn more about play performance of boys with autism and without disabilities in the naturalistic environment within Taiwanese society. Such information might help professionals in understanding of the developmental deficits associated with autism and their effects on play, as well as in the understanding of the general scope of play performance of children without disabilities within Taiwanese society. Those parents were also told that the present study involved three major procedures: (a) the demographic form needed to be filled out by parents (it took 2-3 minutes to complete) (Appendix H), (b) 5-40 minutes test (Chinese Version o f Peabody Picture Vocabulary Test-Revised) needed to be administered to the child to provide an estimate of the child’s developmental age equivalent on receptive knowledge of vocabulary, and (c) the places and times needed to be scheduled to observe the child in a free play situation in a familiar environment with peers present. A total of two sessions were needed: once indoors and once outdoors, each 40 minutes in length. The observational sessions needed to be videotaped to help with the analysis of the play performance of the child. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 104 At the initial visit, the caregivers or parents of the prospective subjects were asked to give their consent for their children’s participation and be videotaped. Their signed informed consent indicated their willingness of participation. In the majority of the prospective subjects, the principal investigator had no difficulty obtaining parental consent of the subject’s participation, and was able to establish an initial rapport and trust between the child and the investigator, and between the parent and the investigator as well. However, many parents had ambiguous expressions and uncertain intentions of participation during the initial visit. They usually requested more days to consider and reach the final decision. There were two kinds of ambiguity in these parents. Some of them had changed their mind and demonstrated the vigorous desire to participate days after the initial visit when they refused to participate, whereas others reached the final decision and returned the signed informed consent days after the initial visit. These kinds of unexpected encounters in the subject recruitment period resulted in more subjects being enrolled in the present research than initially planned. Focused observation and videotaping. When signed parental consents were obtained, the investigator worked with the parents or teachers to schedule the time and place for play observations of the children. Places and times were established where and when the children could be observed in a free play situation in a familiar environment with peers present. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 105 Children were observed at the nursery, at the home of the children, or in preschool settings, depending on what was most convenient or appropriate. If necessary, the caregivers or the parents of prospective subjects were asked to approach the nursery or preschool settings to obtain permission for the investigator to observe and to confirm their approval. Following their contact, the investigator called the nursery or preschool settings to answer any questions and to arrange proper time to visit. For each child, the PPS was administered at least twice, once indoors and once outdoors-each session of observation lasted 40 minutes as a whole. If by any chance, unexpected or unforeseeable interruptions occurred at any time during the observational session that resulted in the observational session lasting less than 40 minutes, this observational session was not used as an eligible session and a new observational session was rearranged. The investigator arranged and made an effort to ensure the order of play observation of the indoors and outdoors in each child, and had been equally distributed across and within groups. Play performance of each child was observed in two whole (40-minute) sessions that were separated by no more than 30 days apart. A calendar was used to assist the investigator to record appointments and to track the observational sessions of each child. The PPS was administered in the manner recommended by Bledsoe and Shepherd (1982), to only one child at a time, although more than one child was present in the play environment. Bledsoe and Shepherd (1982) suggested that before Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 106 actually starting the 30-minute session of observation, the investigator entered and stayed in the environment at least 5 minutes or until the children showed minimal attention to the presence of observer and video camera. In this study, a strategy used for increasing the validity of the recorded data was to begin analyzing the data midway through the observation period (Rocissano, Slade, & Lynch, 1987). The assumption underlying this strategy is that the subjects are most likely to exhibit atypical behavior at the beginning of the session when they are first exposed to the camera (Gross, 1991). Thus, Gross (1991) suggested that if the videotaping session is 40 minutes in length, coding of the data might not begin until 5 minutes into the session. In the present research, the investigator and the research assistant entered and remained in the setting at least 5-10 minutes before starting videotaping (Heacock, Souder, & Chastain, 1996) and the research assistant was instructed to videotape the session for at least 40 minutes. The investigator and the research assistant were the nonparticipants while observing and recording the behavior of the child, and any time in which any of the researchers became active participants in the child’s play were excluded in data analysis. The role of the nonparticipant researcher was facilitated by the fact that there were always other adults present. The teachers and the parents were told in the first visit to recognize that the investigator and the research assistant, were nonparticipants and exerted no authority over the children. The children were told in a variety of ways, which made sense to them by the teachers or by the parents, about Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 107 the presence of the researchers in watching them play for a study project. The indoor play observation was conducted in a familiar and comfortable play environment. The outdoor play observation took place at a naturalistic and familiar playground or neighborhood on rain-free days. The observation took place at a nursery, at preschool settings, or at home of the child, depending on what was most convenient and appropriate. The investigator and the research assistant entered the setting at least 5-10 minutes earlier and remained in the setting, until the child was situated comfortably in the familiar environment. If the child started playing immediately without prompting, the observational session began right away and the assistant started videotaping. If the child did not make initiation to play, the investigator began the session with an instruction to the child: "We (point to the researcher and the research assistant) are here to watch you play and record it with this video camera (point to the video camera). All you need to do is to play the way as you like to do. And we will stay aside and not play with you. L e t’ s start now. You go play. ” During the observation, careful field notes were taken in order to further assist for clarification and discussion of child’s play. The field notes provided background information, including the number of children involved, type of play, toys, equipment, setting, emotions expressed, verbalizations, external influences, what the children were doing immediately prior to or after the observational session, and so on. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 108 When the observational session lasted for 40 minutes as a whole, which satisfied the investigator, the child was interrupted and was told, if no harm to the contextual dynamic, that “ You have been so great on showing us what and how you usually play. Thanks fo r letting us watch you play. Now, we are going to leave. Is there anything else that you would like to show us or to share with us? Thank you very much, good-bye! ” The sessions were videotaped and analyzed subsequently. The videotapes were labeled immediately after each session and were stored in a safe and dry area. The investigator rated observed behavior directly from the videotape using the PPS. The videotapes were viewed and rated only during the investigator’s alert periods to avoid “observer drift” occurred. The observer drift refers to the change or decay in an observer’s accuracy over time, which can occur because of distractions and/or fatigue during lengthy or multiple observation sessions (Gross & Conrad, 1991). Data Recording A variety of data collection methods were used in the present research: (a) videotaped observations, (b) written field notes, (c) demographic form, and (d) standardized assessments. The data from these methods were used to determine whether the significant differences existed in the children’s play age scores versus chronological ages, and play performance between two groups (boys with autism versus boys without disabilities). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 109 Videotaped Observation The primary method of data collection used for the present research was videotaped observation. The child’s play performance was videotaped and analyzed subsequently. Videotaped observation was chosen as the primary method of data collection for this study for several reasons, which will be described below. First, observation method is particularly appropriate for the study of play behavior because of the researcher’s ability to capture the richness of children’s play within natural environments and allow detailed recording of whole complex play behaviors and situations. Videotapes offer efficiency in the data collection process because they record rich and permanent documentation of behaviors (Heacock et al., 1996). Second, videotapes can provide an efficient and reliable record for analysis (Roberts, Srour, & Winkelman, 1996). Videotapes provide an accurate, complete record and minimize the selective bias and memory limitations frequently noted in human observation (Blanck, 1987). Third, videotapes offer observers enormous flexibility when rating or coding observable behavior (Gross & Conrad, 1991). The videotapes can often be replayed to be analyzed in detail and in-depth exploration in order to clarify and further delineate certain aspects of the phenomenon. In other words, researchers can play and replay taped segments as needed to clarify rating research phenomena (Heacock et ah, 1996). Fourth, videotapes allow investigators to conduct the complex features Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 110 of the situation (e.g., environmental, organizational, and interactional patterns) under investigation for further assist to analyze data (Heacock et a l, 1996). Written Field Notes Although videotapes captured the various and complex features of the situation as noted above, the information was restricted to the field of view (the area to be shown on videotape). Therefore, during the observation, careful field notes were taken by the principal investigator in order to provide contextual information not evident in the videotaped recordings. The field notes provided some background information including how children engage prior to the observation, the numbers of children present, type of play, toys, equipment, setting, emotions expressed, verbalizations, external influences, and so on. Demographic Form In addition to videotaping and written field notes of the child’s play, the demographic form was filled out and information was used to further assist in the clarification and discussion of child’s play performance. The demographic questionnaire contained information related as family structure, parental education, and economic level. The demographic questionnaire had been converted to Mandarin/Chinese, and evaluated using a back translation procedure to ensure the accurate translation of the content. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ill Standardized Assessments Two standardized assessments were used in the study: the Revised Preschool Play Scale (PPS) (Bledsoe & Shepherd, 1982; Knox, 1974, 1997), and the Chinese Version o f Peabody Picture Vocabulary Test-Revised (Chinese Version o f PPVT-R) (Lu & Liu, 1998). An overview of these two standardized assessments had been described in the section of instrumentation. The Revised Preschool Play Scale (PPS) (Bledsoe & Shepherd, 1982; Knox, 1974, 1997), an observational scale, was administered for rating and scoring on a developmental level of the play performance exhibited by Taiwanese boys with autism compared with boys without disabilities aged 3 to 5 years old. The Chinese Version o f Peabody Picture Vocabulary Test-Revised (Chinese Version o f PPVT-R) (Lu & Liu, 1998) was also administered on all subjects (i.e., boys with autism and boys without disabilities) by the principal investigator, in order to provide an estimate of the child’s age equivalent on receptive knowledge of vocabulary. The scores from Chinese Version o f PPVT-R test were not used to exclude any prospective participants, but to assist for clarification, interpretation, and discussion of child’s play in this study. Data Processing Scoring the PPS In the present research, all observational sessions of child’s play were videotaped. The videotapes were reviewed and analyzed subsequently, and the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 112 child’s play performances were recorded/rated out from the videotapes on the rating PPS scale. In using PPS, the investigator underlined each behavioral item (factor descriptor) on the scale each time the behavior was observed. If there was no opportunity to observe a specific category or dimension, a no opportunity (N.O.) was recorded, which had no numerical value and was not included in score computation. Unless it was judged that there was no opportunity to observe a category of behavior, this particular behavior was considered absent for a child. After the observation was completed, a child was rated according to the highest age level of factor descriptions that child performed in each category, unless child’s performance of the descriptor was insignificant (i.e., occurring less than 1 minute or by chance). Each category was scored at the upper age of the age grouping. For example, the 36- to 48-month level was scored as 48 months. Category scores within each dimension were averaged to obtain dimension scores. A total score, referred to as the developmental play age, was computed by taking the mean of all four-dimension scores. The PPS was interpreted in accordance with the developmental principals of play. The age level at which a child played and the dimensions manifested in his play aided in evaluation since they showed the habitual performance of the child (Knox, 1974). The scale was utilized in two general ways: (a) determination of a “play age,” an overall level of everyday play behavior; and (b) a profile of the play behavior (Knox, 1974). For normal growth and development, it was important to Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 113 maintain a balance among the four dimensions (Knox, 1974). In this study, the data were treated as a holistic profile and each dimension was also analyzed separately. Information provided from the written field notes, which were recorded by the investigator during the observation, were used to assist for clarification, interpretation, and discussion of child’s play as well. The information demonstrated a holistic nature of child’s play such as trends of behavior, areas of ability or disability, gaps in behavior, stereotyped, or unusual behavior and so on. This kind of information helped to explain why a particular child developed competency within his environment or failed to do so (Knox, 1974). Data Analysis All statistical results and detailed data analysis will be described later in next chapter as the result section. This section will explain the selections of statistical strategies with specifically corresponding to the proposed hypotheses. All the videotapes of child’s play were reviewed and the child’s performance were recorded/rated out from the videotapes on the rating PPS scale by the principal investigator. Additionally, the written field notes recorded by the principal investigator, and the demographic information provided by the parents, were used to assist for clarification, interpretation, and discussion of child’s play. All data were computed and analyzed utilizing SPSS statistical package. The means, standard deviations, and ranges of scores obtained for the two groups on the PPS and its four dimensions were computed. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 114 To test Hypothesis 1, that “significant differences would exist between boys without disabilities and boys with autism on the mean scores of the PPS and its four dimensions,” the t-test was used. This hypothesis was the comparison of two groups of subjects with respect to mean values on a dependent variable. The independent t- test was computed to determine whether the significant difference existed between the mean play ages of the group of children with autism and the group of children without disabilities, as well as within each subsection of the PPS. Since five t-tests were calculated, the more conservative pooled variance estimate and two-tailed probability were used (Polit & Hungler, 1995). This reduced the possibility that at least one t-test would be statistically significant by chance (i.e., that a Type I error would occur). The paired t-test was also computed to test Hypothesis 2 that, “significant differences would exist between the developmental play age and chronological age of the children, only in the group of boys with autism and not in the group of boys without disabilities.” As a descriptive statistic, the most common method to identify the relationship between two measures is through correlation procedures; and relationships, from a statistical point of view, are concerned with how variations in one variable are associated with variations in another; that is, the correlation coefficient summarizes the magnitude and direction of a relationship between two variables (Polit & Hungler, 1995). To test Hypothesis 3, that “the correlation between chronological age and play age, and between chronological age and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 115 dimension scores would be significantly higher within the group of boys without disabilities than within the group of boys with autism,” three steps of statistical analysis were performed. First, the correlation coefficient of the chronological age on the PPS age scores for each of the two samples was computed; and further, Fisher’s z transformation of the sample correlation coefficient was calculated; finally, Fisher’ s z test was performed to statistically compare two sets of correlation coefficients in two samples for the hypothesis test. To test Hypothesis 4, that “age level scores on the PPS and its four dimensions would correctly predict group membership of the subjects,” two stepwise discriminant analysis were computed. Theoretically, Discriminant analysis makes predictions about membership in categories or groups (Polit & Hungler, 1995). The purpose of the analysis is to distinguish groups from one another on the basis of available independent variables. The analysis produces an index, is known as Wilks ’ lambda, designating the proportion of variance in the dependent variable accounted for the predictor variables (Polit & Hungler, 1995). In this study, the overall age score from the PPS was entered into the first analysis to obtain the classification rates, by group, from this analysis. The age scores from each of the four dimensions were included in the second analysis for the same purpose. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 116 CHAPTER IV RESULTS/RESEARCH FINDINGS This study was designed to provide data derived from the naturalistic observation of two samples of children in a familiar environment engaging in spontaneous performance of play. The following section presents results of this study in quantitative terms and in table form, along with a descriptive explanation, which is organized to address the research questions posed earlier in the study. This chapter will be organized around these research questions and hypotheses that guided the treatment of the data. In order to facilitate the reader in gaining further understanding of the research results, the description of final samples and observation sites will be provided first, followed by the sections of demographics information, results on Chinese Version of PPVT-R, and research findings corresponding to the research questions and hypotheses, respectively. Description o f Final Samples Normal Samples The general criteria of age and gender, along with the introductory brochure, were given to teachers in the day-care center/kindergarten as their reference. The teachers distributed the introductory brochure and made the initial contact with the potential participant’s parents as part of the information changed in regular daily routines. Then, the researcher obtained a contact list from teachers for these potential participants parents who agreed to share their phone numbers with the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 117 researcher. From the information and phone number provided in the introductory brochure, two parents called the researcher and showed their interests in participating. Four parents approached the researcher to request they be involved in the participation at the time they pick up their children after school. The researcher contacted 42 parents from the list to ask for their participation. In total, there were 48 potential samples whose parents either showed interest or were willing to be contacted for further participation. O f these contacts, one rejection was received because the parents did not want their child to be videotaped. One boy was excluded because his attendance at the day care center was not as regular as the others, and there was difficulty in arranging the observation sessions with the parents. Two boys were excluded because they were taking medicine for the flu that may have affected their daily behavior. Thirteen parents demonstrated some degrees of reluctance for participation and requested more time to make the final decision. Out of these 13, two ended up with declining because of the same concerns of being videotaped, and the rest gave their consent to participate. In sum, 42 boys were recruited in this study. The numbers of samples in the process of recruitment can be found in Table 3. Autistic Samples In this study, the boys with autism were recruited from a hospital of a university in Tainan. The autistic samples referred to the boys who had received a psychiatric diagnosis of autistic disorder based on the criteria for diagnosis set forth Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 118 in D SM IV (APA, 1994), and diagnosed by the special interdisciplinary team of clinicians in the general hospital. These samples consisted of the boys who visited this hospital for services at the time or the boys who had been seen in this hospital during the last two years who were likely to meet the eligibility criteria based upon medical documentation. Once the researcher received the contact information of the potential participants, the researcher contacted these parents to explain the study and to further elicit their support for participation in the same manner as the boys without disabilities. In total, the researcher contacted 53 parents in the entire period of subject recruitment. Through the phone contact, three boys were excluded because they were taking medication for the flu or other physical discomfort; 5 parents firmly refused to participate, 23 parents demonstrated highly level of interest in participating, and the rest of the 22 parents requested more time to make a decision. Finally, out of these 22, 8 parents declined, and the other 14 parents signed the consent for participation. Among these 13 parents who refused to participate in the study, 4 parents strongly demonstrated feeling offended when they were informed about the videotaping the child’s behavior. Others showed a friendlier attitude, but conservatively responded to participating. In sum, 37 boys with autism were recruited in this study. The numbers of samples in the process of recruitment can be found in Table 3. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 119 Table 3: Subject Recruitment in the Data Collection Process B o y s w i t h a u t i s m B o y s w i t h o u t d i s a b i l i t i e s R e s e a r c h e r m a d e t h e p h o n e c o n t a c t 5 3 4 2 P a r e n t s i n i t i a l l y c o n t a c t r e s e a r c h e r b y p h o n e 0 2 P a r e n t s i n i t i a l l y c o n t a c t r e s e a r c h e r i n p e r s o n 0 4 I n i t i a l c o n t a c t s ( t o t a l ) 5 3 4 8 N = 5 3 N = 4 8 n ( % ) n ( % ) S u b j e c t s w e r e e x c l u d e d ( t a k i n g m e d i c i n e ) ( - ) 0 3 5 .6 ( - ) 0 2 4 . 2 S u b j e c t s w e r e e x c l u d e d ( i r r e g u l a r s c h e d u l e ) ( - ) 0 1 2 .1 P a r e n t s a g r e e d t o p a r t i c i p a t e i n t h e f i r s t c o n t a c t ( + ) 2 3 4 3 . 4 ( + ) 3 1 6 4 . 6 P a r e n t s r e f u s e d t o p a r t i c i p a t e i n t h e f i r s t c o n t a c t ( - ) 0 5 9 .4 ( - ) 0 1 2 .1 P a r e n t s r e q u e s t e d m o r e t i m e t o m a k e d e c i s i o n 2 2 4 1 . 5 13 2 7 .1 ( a ) P a r e n t s a g r e e d to p a r t i c i p a t e ( t h i n k it o v e r ) (+) 1 4 2 6 . 4 ( + ) 1 1 2 2 . 9 ( b ) P a r e n t s r e f u s e d t o p a r t i c i p a t e ( t h i n k i t o v e r ) ( - ) 0 8 1 5 .1 ( - ) 0 2 4 . 2 F i n a l s a m p l e s ( t o t a l ) 3 7 6 9 .8 4 2 8 7 .5 Description o f Observation Sites Normal Samples All the participants attended whole day sessions, five days a week in the day care center/kindergarten. All children were normally developing and were observed both indoors and outdoors in their day care center/kindergarten. The 42 normal preschoolers were part of approximately 110 children divided by age level into three Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 120 groups. Each group was then split up into two adjoining classrooms. Each classroom was filled with a teacher, an assistant, and sometimes with volunteers. The indoor setting was organized into with three major activity areas: (a) a carpet area for quiet activities (e.g., book-reading, story-sharing, tutoring), (b) sets of low tables for fme-work activities (e.g., painting, puzzles, building/constructive materials), and (c) a wide-open space with surrounding open shelves which had a variety of accessible toys. These indoor classrooms opened onto two large outdoor playground areas. Equipment found in these playgrounds included several climbing structures, ladders, string nets, suspension bridges, swings, money bars, balance beams, tunnels, slides, enclosures for dramatic play, roofed play house with a kitchen stove counter, balls of different sizes, tricycles, wagons, other wheeled vehicles, and sand areas. Due to the schedule of preschool classes, a 10-15 minute short recess was arranged between every 40-50 minute academic session. In addition, there was a 30- 45 minute free play session in every morning and afternoon period. In the morning before class began and in the afternoon after class ended, waiting periods were also available for free play. Past research suggests that children being videotaped in research were most likely to exhibit atypical behavior at the beginning of the session when they are first exposed to the camera (Gross, 1991). In order to increase the validity of the recorded data, a strategy of beginning analysis of the data midway through the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 121 observation period was suggested (Rocissano et ah, 1987). Gross (1991) also suggested that coding of the data might not begin until five minutes into the session. In this study, the research assistants were instructed to videotape the session for at least 40 minutes as a complete eligible session. The research observations occurred in these recess periods that lasted longer than 40 minutes. There were four occasions when the teachers called the time up or the parents came to pick up the child, which made the observation period less than 40 minutes as a whole session with just a little gap of time. Eventually, the teachers and parents were willing to wait for a few minutes to make the session a whole period. Therefore, for all normal samples, there was no observation or videotaping session for any child that needed to be discarded or be redone. Autistic Samples Out of the 37 subjects with autism, 21 (57%) attended the mainstream regular preschools or kindergartens near their neighborhood, 13 (35%) attended various day care centers for children with special needs, and 3 (8%) were taken care of by their mother and stayed at home. The settings in these kindergartens and centers obviously presented differences that will not be discussed in detail here. The places and times for the research observation of child’s free play were arranged with the child’s parents with respect to when and where they thought it would be convenient or appropriate. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 122 Indoor observations. Out of the 37 subjects with autism, 28 (76%) were observed in the day care centers or kindergartens where they attended; and 9 (24%) were observed in their own home. Outdoor observations. Out of 23 observations, 23 (62%) took place at the outdoor playground of the day care centers and kindergartens where they attended; and the other 14 observations (38%) occurred in the playgrounds near the neighborhood where they lived. The parents were asked to approach the preschools to explain the situation and to obtain permission for the researcher to observe in the preschool sites where the child attended. All but one of these preschool sites requested the researcher to make a brief presentation, and to meet with the directors and teachers prior to giving their approval. Nevertheless, all the chairpersons of these sites gave their approval in cooperation with the researcher after the presentation. If by any chance unexpected or unforeseeable interruptions occurred at any time during the observational session that would result in the session being less than 40 minutes, the session was not used as an eligible session and a new observational session was rearranged. In total, three observation sessions were considered as incomplete ones, and were discarded and rearranged for the second observation. O f these three sessions, one was forced to discontinue due to rain. The other two sessions were cut off Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 123 because these two children were too tired, had tantrums throughout the session, and one child even fell asleep from the very beginning of the session. Demographics Seventy-nine boys whose primary language is Mandarin/Chinese participated in this research, 37 boys with autism and 42 boys without disabilities. The characteristics and family demographic information of these subjects can be found in Table 4. All participants in the autistic group were diagnosed by expert clinicians based on the criteria in D S M IV (APA, 1994), while boys in the normal group were judged by their parents as typically-developing in screening questionnaires. Each normal subject had to have no reported or any observable psychiatric, psychological, physiological, or neurological problems, which would interfere with the ability of the subject to participate in the study. All the subjects had to be between the ages of 3.0 years and 5.11 years at the time of the study, and were divided into three age categories: age 3-4, 4-5, and 5-6 years. The mean age of the boys with autism was 54.2 months (SD = 9.5 months; range = 3 years 1 month to 5 years 11 months), and the mean age of the boys without disabilities was 54.4 months (SD = 10.0; range = 3 years 2 months to 5 years 11 months). No statistically significant difference between groups for chronological age (p = 0.93) was revealed. Among these demographic data, it is interesting to note that differences between groups were significant (p< .05) in three areas: (a) primary caregiver at Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 124 daytime in weekdays, (b) family income, and (c) father’s educational level. Apparently, in this study, the families with autistic children showed a tendency of having a lower monthly income than did the families with normal children. Proportionally, 55% of families with normal children and 19% o f families with autistic children had monthly incomes over than 80,000 NT dollars (US $2,300). Conversely, 15% of families with normal children and 48% of families with autistic children had monthly incomes less than 50,000 NT dollars (US $1,450). The groups were also found to be different in the area of subject’s primary caregiver at daytime in the weekdays (p < 0.01). Approximately 50% of the autistic subjects were taken care of by parents or grandparents, particularly the mother (39%), whereas 98% of the normal subjects were supervised under preschool teachers at the daytime in the weekdays. In addition, the result also indicated that the fathers in normal groups accomplished higher educational levels than did the fathers in the autistic group, and the difference reached the .01 significance level. Over the past 50 years of research in autism, researchers had examined and had argued the findings regarding children with autism are over-represented in either high or low family socioeconomic status (SES) and no convincing evidence that has been provided to make firm conclusions (Bristol, 1985; Bristol & Schopler, 1983; Cantwell, Baker, & Rutter, 1978; DeMyer, 1979; Gillberg & Schaumann, 1982; McCubbin, Cauble, & Patterson, 1982; Schopler, Andrews, & Strupp, 1979; Schopler & Mesibov, 1984; Tsai, Stewart, Faust, & Shook, 1982). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 125 T a b l e 4 : C h a r a c t e r i s t i c s a n d F a m i l y D e m o g r a p h i c I n f o r m a t i o n o f S u b j e c t s B o y s w i t h a u t i s m B o y s w i t h o u t d i s a b i l i t i e s ( N = 3 7 ) ( N = 4 2 ) X 2 P n ( % ) n ( % ) C h r o n o l o g i c a l a g e 3 . 0 ~ 3 .1 1 ( y e a r s - m o n t h s ) 1 0 ( 2 7 . 0 ) 1 3 ( 3 1 . 0 ) 0 .7 9 2 0 .6 7 3 I o 1 5 ( 4 0 .5 ) 1 3 ( 3 1 . 0 ) 5 . 0 - 5 . 1 1 1 2 ( 3 2 .4 ) 1 6 ( 3 8 . 1 ) P e r s o n w h o f i l l o u t f o r m s F a t h e r 2 ( 6 . 7 ) 1 0 ( 2 3 . 8 ) 3 .7 1 2 0 . 1 5 6 M o t h e r 2 7 ( 9 0 . 0 ) 3 1 ( 7 3 . 8 ) O t h e r s 1 ( 3 .3 ) 1 ( 2 .4 ) F a m i l y i n c o m e / m o n t h * L e s s t h a n N T S 1 0 0 0 0 2 ( 7 . 4 ) - 1 4 .5 7 6 0 . 0 1 2 N T S 1 0 0 0 0 - 3 0 0 0 0 5 ( 1 8 . 5 ) 1 ( 2 .5 ) N T S 3 0 0 0 0 - 5 0 0 0 0 6 ( 2 2 . 2 ) 5 ( 1 2 . 5 ) N T S 5 0 0 0 0 - 8 0 0 0 0 9 ( 3 3 . 3 ) 1 2 ( 3 0 . 0 ) N T S 8 0 0 0 0 - 1 0 0 0 0 0 4 ( 1 4 . 8 ) 1 2 ( 3 0 . 0 ) M o r e t h a n N T S 1 0 0 0 0 0 1 ( 3 .7 ) 1 0 ( 2 5 . 0 ) P r i m a r y c a r e g i v e r a t d a y t i m e i n w e e k d a y s ** B o t h p a r e n t 1 ( 2 .8 ) - 2 4 . 7 6 8 < 0 . 0 0 1 T e a c h e r 1 7 ( 4 7 . 2 ) 3 9 ( 9 7 . 5 ) G r a n d p a r e n t s 2 ( 5 . 6 ) - M o t h e r 1 4 ( 3 8 . 9 ) 1 ( 2 . 5 ) F a t h e r 1 ( 2 .8 ) - O t h e r s 1 ( 2 .8 ) - Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 126 Table 4 (continued) B o y s w i t h a u t i s m B o y s w i t h o u t d i s a b i l i t i e s ( N = 3 7 ) ( N = 4 2 ) X 2 P n ( % ) n ( % ) P r i m a r y c a r e g i v e r a t n i g h t t i m e in w e e k d a y s B o t h p a r e n t 1 4 ( 3 8 .9 ) 1 7 ( 4 1 . 5 ) 3 . 6 2 2 0 .4 6 0 G r a n d p a r e n t s 2 ( 5 . 6 ) 2 ( 4 . 9 ) M o t h e r 1 7 ( 4 7 .2 ) 2 2 ( 5 3 . 7 ) F a t h e r 1 ( 2 .8 ) - O t h e r s 2 ( 5 . 6 ) - P r i m a r y c a r e g i v e r a t d a y t i m e in w e e k e n d B o t h p a r e n t 1 5 ( 4 2 . 9 ) 1 9 ( 4 6 . 3 ) 2 .2 1 1 0 .6 9 7 G r a n d p a r e n t s 2 ( 5 . 7 ) 3 ( 7 . 3 ) M o t h e r 1 6 ( 4 5 .7 ) 1 6 ( 3 9 . 0 ) F a t h e r 1 ( 2 .9 ) 3 ( 7 . 3 ) O t h e r s 1 ( 2 .9 ) - P r i m a r y c a r e g i v e r a t n i g h t t i m e in w e e k e n d B o t h p a r e n t 1 6 ( 4 5 . 7 ) 2 0 ( 5 0 . 0 ) 1 .7 8 6 0 .7 7 5 G r a n d p a r e n t s 1 ( 2 .9 ) 2 ( 5 . 0 ) M o t h e r 1 6 ( 4 5 . 7 ) 1 6 ( 4 0 . 0 ) F a t h e r 1 ( 2 .9 ) 2 ( 5 . 0 ) O t h e r s 1 ( 2 .9 ) - S i t e s w h e r e c h i l d s t a y s a t t h e d a y t i m e i n w e e k d a y s C h i l d ’s o w n h o m e 3 ( 8 . 1 ) 2 ( 4 . 8 ) 5 .3 3 3 0 . 0 6 9 S c h o o l / D a y c a r e c e n t e r 3 0 ( 8 1 . 1 ) 4 0 ( 9 5 . 2 ) O t h e r s 4 ( 1 0 . 8 ) - Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 127 Table 4 (continued) B o y s w i t h a u t i s m ( N = 3 7 ) B o y s w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) X 2 P n ( % ) n ( % ) S i t e s w h e r e c h i l d s t a y s a t t h e n i g h t t i m e i n w e e k d a y s 3 . 5 4 0 0 .0 9 8 C h i l d ’s o w n h o m e 3 4 ( 9 1 . 9 ) 4 2 ( 1 0 0 . 0 ) O t h e r s 3 ( 8 . 1 ) - S i t e s w h e r e c h i l d s t a y s a t t h e d a y t i m e i n w e e k e n d 1 .6 3 2 0 . 2 3 4 C h i l d ’s o w n h o m e 2 7 ( 7 7 . 1 ) 3 7 ( 8 8 . 1 ) O t h e r s 8 ( 2 2 . 9 ) 5 ( 1 1 . 9 ) S i t e s w h e r e c h i l d s t a y a t t h e n i g h t t i m e i n w e e k e n d 1 .0 4 6 0 . 4 5 7 C h i l d ’s o w n h o m e 3 0 ( 8 5 . 7 ) 3 9 ( 9 2 . 9 ) O t h e r s 5 ( 1 4 . 3 ) 3 ( 7 . 1 ) S p e c i a l t h e r a p e u t i c / m e d i c a l s e r v i c e s r e c e i v e d * * 6 3 . 0 9 9 < 0 . 0 0 1 N o 2 ( 6 . 9 ) 4 2 ( 1 0 0 . 0 ) Y e s 2 7 ( 9 3 . 1 ) - B o y w i t h a u t i s m ( N = 3 7 ) B o y w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) T P M e a n ( S D ) M e a n ( S D ) C h r o n o l o g i c a l a g e ( m o n t h s ) 5 4 . 2 ( 9 . 5 ) 5 4 . 4 ( 1 0 . 0 ) - 0 .0 8 8 0 . 9 3 0 T o t a l n u m b e r o f c h i l d r e n i n t h e f a m i l y 2 . 1 ( 0 . 6 ) 2 . 3 ( 0 . 9 ) - 0 . 8 4 6 0 . 4 0 0 F a t h e r ’s e d u c a t i o n a l le v e l ( y e a r s ) ** 1 2 . 2 ( 3 .0 ) 1 4 . 5 ( 2 .4 ) - 3 . 5 9 4 0 .0 0 1 M o t h e r ’s e d u c a t i o n a l le v e l ( y e a r s ) 1 2 . 7 ( 2 .4 ) 1 3 . 3 ( 1 .9 ) - 1 . 2 4 8 0 . 2 1 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 128 Specially, for example, in analyses done by Schopler, Andrews, and Strupp (1979), 12 out of 18 studies reported a predominance of high SES families with autistic children. Conversely, the results of a statewide study of 264 autistic children indicated that 61% of the autistic children came from the families of lower SES, and only 22% of the samples were in the families of a higher SES (Schopler et ah, 1979). Subsequent studies also reported a tendency of low family socioeconomic status (SES) of autistic children (Gillberg & Schaumann, 1982; Tsai, Stewart, Faust, & Shook, 1982). In this study, the groups differed significantly on certain domains of SES (i.e., family income and father’s educational level). The researcher had examined the association between the particular domain of SES (i.e., separately examined family income and father’s educational level), and scores on PPS in the subjects without disabilities. The results can be found in Table 5 and Table 6. As can be seen in Table 5, the one-way analysis of variance (ANOVA) revealed no statistically significances among normal subjects with different levels of family economical status on the PPS scores. Similarly, as reported in Table 6, the ANOVA also revealed no significant differences on subjects’ PPS scores among different father’s educational levels of boys without disabilities. Thus, analyses indicated neither of these two SES variables had the effect on subjects’ PPS scores. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 129 T a b l e 5 : M e a n S c o r e s a n d S t a n d a r d D e v i a t i o n f o r D i f f e r e n t F a m i l y E c o n o m i c a l L e v e l s o f B o y s w i t h o u t D i s a b i l i t i e s o n P r e s c h o o l P l a y S c a l e b y C a t e g o r y , D i m e n s i o n , a n d T o t a l P l a y A g e F a m i l y I n c o m e ( p e r m o n t h ) F P L e s s t h a n N T $ 5 0 0 0 0 - 8 0 0 0 0 M o r e t h a n N T $ 5 0 0 0 0 ( n = 6 ) ( n = 1 2 ) N T S 8 0 0 0 0 ( n = 2 2 ) P P S C o m p o n e n t s M e a n S D M e a n S D M e a n S D S p a c e m a n a g e m e n t 6 0 . 0 0 7 .5 8 5 9 . 5 0 1 0 .3 7 5 5 .6 3 7 . 8 9 1 .0 7 6 0 .3 5 1 G r o s s m o t o r 6 4 . 0 0 9 . 8 0 6 2 . 0 0 1 2 .3 6 5 7 . 2 7 9 .7 5 1 .3 5 3 0 .2 7 1 I n t e r e s t 5 6 . 0 0 6 . 2 0 5 7 . 0 0 9 .0 5 5 4 . 0 0 7 . 1 7 0 . 6 3 4 0 . 5 3 6 M a t e r i a l m a n a g e m e n t 6 2 . 0 0 7 .0 1 6 3 .2 5 6 .7 0 5 8 . 3 6 8 . 0 0 1 .8 1 0 0 . 1 7 8 M a n i p u l a t i o n 6 2 . 0 0 1 1 ,8 0 6 3 . 0 0 1 0 .3 9 5 6 .7 3 1 1 .2 2 1 .4 4 3 0 . 2 4 9 C o n s t r u c t i o n 5 6 . 0 0 9 . 8 0 5 7 . 0 0 9 .0 5 5 2 .9 1 1 1 .5 1 0 . 6 3 9 0 .5 3 3 P u r p o s e 5 8 . 0 0 9 .0 3 6 1 . 0 0 9 . 5 2 5 1 . 8 2 1 0 .7 2 3 .3 8 5 0 .0 4 5 A t t e n t i o n 7 2 . 0 0 0 . 0 0 7 2 . 0 0 0 . 0 0 7 2 . 0 0 0 . 0 0 - - P r e t e n s e / s y m b o l i c 6 0 . 0 0 1 3 .1 4 5 4 . 7 5 1 2 .4 1 5 0 .1 8 1 2 .4 6 1 .6 0 7 0 . 2 1 4 I m i t a t i o n 6 0 . 0 0 1 3 .1 5 5 5 . 0 0 1 1 .9 5 5 0 .4 5 1 2 .0 9 1 .6 1 9 0 . 2 1 2 D r a m a t i z a t i o n 6 0 . 0 0 1 3 .1 5 5 4 . 5 0 1 2 .9 1 4 9 .9 1 1 2 .8 8 1 .5 8 5 0 . 2 1 9 P a r t i c i p a t i o n 5 8 . 7 5 1 2 .2 3 5 7 . 1 2 1 0 .6 3 4 9 . 9 0 1 2 .9 6 2 .0 3 1 0 . 1 4 6 T y p e 6 4 . 0 0 9 . 8 0 6 2 . 0 0 8 .6 1 5 4 . 8 2 1 3 .6 4 2 . 2 2 4 0 . 1 2 2 C o o p e r a t i o n 6 0 . 0 0 1 3 .1 5 5 7 . 5 0 1 3 .4 1 5 2 . 0 9 1 4 .8 6 1 .0 1 6 0 . 3 7 2 H u m o r 5 5 . 0 0 1 4 .4 1 5 1 . 0 0 1 2 .4 0 4 2 . 8 2 1 2 .4 6 2 . 9 6 5 0 . 0 6 4 L a n g u a g e 5 6 . 0 0 1 4 .5 3 5 8 . 0 0 1 2 .3 6 4 9 .9 1 1 3 .5 3 1 .5 7 9 0 . 2 2 0 P P S ( P l a y a g e ) 6 0 . 1 8 9 . 6 2 5 8 . 6 5 8 .7 6 5 3 . 5 2 9 .6 5 1 .8 4 0 0 . 1 7 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 130 T a b l e 6 : M e a n S c o r e s a n d S t a n d a r d D e v i a t i o n f o r D i f f e r e n t F a t h e r ’s E d u c a t i o n a l L e v e l s o f B o y s w i t h o u t D i s a b i l i t i e s o n P r e s c h o o l P l a y S c a l e b y C a t e g o r y , D i m e n s i o n , a n d T o t a l P l a y A g e F a t h e r ’s E d u c a t i o n a l L e v e l ( i n y e a r s ) F P P P S C o m p o n e n t s 6 & 1 2 Y e a r s ( n = I 2 ) 1 4 Y e a r s ( n = 1 2 ) 1 6 & 1 8 Y e a r s ( n = 1 8 ) M e a n S D M e a n S D M e a n S D S p a c e m a n a g e m e n t 5 6 . 5 0 1 0 .3 7 6 1 . 5 0 7 . 2 9 5 4 .3 3 7 .5 5 2 . 6 6 2 0 . 0 8 2 G r o s s m o t o r 5 9 . 0 0 1 3 .0 0 6 4 . 0 0 9 . 3 4 5 6 . 0 0 9 . 2 0 2 .1 1 1 0 .1 3 5 I n t e r e s t 5 4 . 0 0 8 .0 9 5 9 . 0 0 6 .1 8 5 2 . 6 7 7 . 2 9 2 . 8 7 3 0 . 0 6 9 M a t e r i a l m a n a g e m e n t 6 1 . 5 0 7 .8 3 6 2 . 5 0 6 .6 2 5 7 . 1 6 7 .9 3 2 . 1 5 5 0 . 1 2 9 M a n i p u l a t i o n 6 2 . 0 0 1 0 .0 2 6 3 . 0 0 1 0 .3 9 5 4 . 0 0 1 1 .0 8 3 .3 3 5 0 . 0 4 6 C o n s t r u c t i o n 5 4 . 0 0 1 0 .8 5 5 8 . 0 0 1 0 .0 2 5 1 .3 3 1 0 .7 4 1 .4 3 1 0 .2 5 1 P u r p o s e 5 8 . 0 0 1 2 .3 6 5 7 . 0 0 9 .0 5 5 1 .3 3 1 0 . 7 4 1 .7 0 6 0 .1 9 5 A t t e n t i o n 7 2 . 0 0 0 . 0 0 7 2 . 0 0 0 . 0 0 7 2 . 0 0 0 . 0 0 - - P r e t e n s e / s y m b o l i c 5 3 .7 5 1 4 .3 8 5 3 . 7 5 1 3 .4 4 5 0 .8 3 1 1 .5 7 0 .2 6 1 0 . 7 7 2 I m i t a t i o n 5 4 . 0 0 1 4 .0 1 5 4 . 0 0 1 3 .0 5 5 1 . 0 0 1 1 .3 2 0 .2 9 1 0 . 7 4 9 D r a m a t i z a t i o n 5 3 . 5 0 1 4 .8 0 5 3 . 5 0 1 3 .8 9 5 0 . 6 7 1 1 .8 6 0 . 2 3 3 0 . 7 9 4 P a r t i c i p a t i o n 5 7 . 0 0 1 0 .9 1 5 5 . 5 0 1 3 .9 6 4 8 . 5 8 1 1 .4 8 2 . 1 1 5 0 . 1 3 4 T y p e 6 2 . 0 0 1 0 .0 2 5 8 . 5 0 1 4 .0 4 5 4 . 6 7 1 1 .8 0 1 .3 6 2 0 . 2 6 8 C o o p e r a t i o n 5 9 . 0 0 1 1 .9 5 5 7 . 5 0 1 4 .3 5 4 9 . 6 7 1 4 .0 8 2 . 0 8 7 0 . 1 3 8 H u m o r 5 1 . 0 0 1 2 .4 0 5 1 . 0 0 1 3 .4 2 4 1 . 0 0 1 2 .2 2 3 . 2 3 0 0 . 0 5 0 L a n g u a g e 5 6 . 0 0 1 2 .8 8 5 5 . 0 0 1 6 .5 5 4 9 . 0 0 1 1 .3 2 1 .2 2 5 0 . 3 0 5 P P S ( P l a y a g e ) 5 7 . 1 8 1 0 .0 2 5 8 .3 1 9 . 9 2 5 2 . 7 2 8 . 8 0 1 .4 8 4 0 . 2 3 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 131 Results on Chinese Version of Peabody Picture Vocabulary Test-Revised In this study, the Chinese Version of PPVT-R was chosen to administer on all subjects for the purpose of providing an estimate of receptive knowledge of vocabulary of subjects. The reasons and advantages of utilizing this test are: (a) the Chinese Version of the test and the normative tables had already been established for the Taiwanese population, so each subject’s performance could be validly and reliably compared with other Taiwanese children of the same age; (b) the test can be given to the very young toddlers from age 2 years 6 months and above; and (c) since the test requires no reading ability and responses are non-oral, it is appropriate for the speech impaired individuals, and has been highly recommended to administer to autistic persons (Dunn, 1965; Dunn & Dunn, 1981; Lu & Liu, 1998). As noted, the PPVT-R was designed to “provide an estimate of a subject’s verbal intelligence through measuring his/her hearing vocabulary” (Dunn, 1965, p.25). The subject’s raw score on the test can be obtained conveniently and can be converted to three types of derived scores: (a) age equivalent (mental age), (b) standard score equivalent (intelligence quotient), and (c) percentile equivalent (Dunn, 1965). However, only two types of these norms, standard score and percentile equivalent were established in the Taiwanese population, and only the subject’s raw score and standard score, which can be handled easily by statistics, were presented in the result of the present study. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 132 For the readers’ information, the raw score on the test is the number of correct responses made by subject, whereas the standard score (intelligence quotient score) provides an index of brightness for a given subject in comparison with other individuals in his/her same age group, in addition, raw scores are converted into standard scores, with a mean of 100 and standard deviation of 15, thus, the standard scores range between 55 and 145 (Dunn, 1965). In the procedure for converting raw scores to standard scores among the subjects with autism in the present study, one technical problem occurred, that there were three subjects who obtained extremely low raw scores that fell below the 55 limit of the converted standard score. Although the additional tables of extrapolated standard score value had been established for those extremely low or high scoring children in the original version (Dunn, 1965), no similar information was drawn up in the Chinese Version of PPVT- R for the Taiwanese population. Therefore, the numerical values of these three subjects’ standard scores were obtained by calculating proportionally in both the last vertical and horizontal directions of the available values for the subjects’ age level at the established Taiwanese normative data in the manual. A summary of how the Chinese Version of PPVT-R was administered to the subjects and their performances is presented in Table 7. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 133 T a b l e 7 : P e r f o r m a n c e o n C h i n e s e V e r s i o n o f P e a b o d y P i c t u r e V o c a b u l a r y T e s t - R e v i s e d f o r B o y s w i t h A u t i s m a n d B o y s w i t h o u t D i s a b i l i t i e s B o y s w i t h a u t i s m ( N = 3 7 ) B o y s w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) X 2 P n ( % ) n ( % ) A d m i n i s t r a t i o n o n C h i n e s e V e r s i o n o f P P V T - R * * 2 8 . 3 9 7 < 0 .0 0 1 ( a ) T e s t - c o m p l e t e d i n d e p e n d e n t l y 1 8 ( 4 8 .6 ) 4 2 ( 1 0 0 . 0 ) ( b ) T e s t - c o m p l e t e d w i t h a s s i s t a n c e 6 ( 1 6 . 2 ) - ( c ) C a n n o t b e t e s t e d 1 3 ( 3 5 .1 ) - 3 6 - 4 1 m o n t h s 4 ( 4 / 4 = 1 0 0 . 0 ) 0 ( 0 / 6 = 0 ) 4 2 - 4 7 m o n t h s 1 ( 1 / 6 = 1 6 . 7 ) 0 ( 0 / 7 = 0 ) 4 8 - 5 3 m o n t h s 5 ( 5 / 9 = 5 5 . 6 ) 0 ( 0 / 6 = 0 ) 5 4 - 5 9 m o n t h s 1 ( 1 / 6 = 1 6 . 7 ) 0 ( 0 / 7 = 0 ) 6 0 - 6 5 m o n t h s 2 ( 2 / 7 = 2 8 . 6 ) 0 ( 0 / 6 = 0 ) 6 6 - 7 1 m o n t h s 0 ( 0 / 5 = 0 ) 0 ( 0 / 1 0 = 0 ) B o y s w i t h a u t i s m ( N - 2 4 ) B o y s w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) T p n R a w s c o r e M e a n ( S D ) n R a w s c o r e M e a n ( S D ) C h r o n o l o g i c a l a g e 3 6 - 4 1 m o n t h s 0 ( 0 / 4 ) - 6 ( 6 / 6 ) 3 0 . 8 ( 5 . 0 ) - - 4 2 - 4 7 m o n t h s * 5 ( 5 / 6 ) 1 8 . 0 ( 1 3 .9 ) 7 ( 7 / 7 ) 3 9 . 3 ( 1 1 . 0 ) 2 . 9 6 9 0 . 0 1 4 4 8 - 5 3 m o n t h s * * 4 ( 4 / 9 ) 1 3 . 0 ( 8 .8 ) 6 ( 6 / 6 ) 4 2 . 7 ( 6 . 9 ) 6 . 0 1 3 < 0 .0 0 1 5 4 - 5 9 m o n t h s * * 5 ( 5 / 6 ) 2 5 . 0 ( 1 8 . 7 ) 7 ( 7 / 7 ) 5 5 . 0 ( 5 . 1 ) 4 . 1 0 2 0 . 0 0 2 6 0 - 6 5 m o n t h s * * 5 ( 5 / 7 ) 2 3 . 6 ( 1 7 . 5 ) 6 ( 6 / 6 ) 5 8 . 2 ( 7 . 9 ) 4 . 0 8 4 0 . 0 0 8 6 6 - 7 1 m o n t h s * 5 ( 5 / 5 ) 2 8 . 2 ( 1 5 . 6 ) 1 0 ( 1 0 / 1 0 ) 5 8 . 4 ( 3 . 7 ) 4 . 2 5 8 0 . 0 1 2 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 134 Table 7 (continued) B o y s w i t h a u t i s m ( N = 2 4 ) B o y s w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) T P S t a n d a r d s c o r e n M e a n ( S D ) n S t a n d a r d s c o r e M e a n ( S D ) C h r o n o l o g i c a l a g e 3 6 - 4 1 m o n t h s 0 ( 0 / 4 ) 6 ( 6 / 6 ) 1 2 0 . 1 7 ( 5 . 3 8 ) - - 4 2 - 4 7 m o n t h s * 5 ( 5 / 6 ) 9 7 . 6 0 ( 2 1 . 3 8 ) 7 ( 7 / 7 ) 1 2 7 . 0 0 ( 1 0 . 5 5 ) 3 .1 7 7 0 . 0 1 0 4 8 - 5 3 m o n t h s * 4 ( 4 / 9 ) 7 6 . 0 0 ( 2 5 . 4 7 ) 6 ( 6 / 6 ) 1 1 9 . 3 3 ( 5 . 1 3 ) 3 .3 5 8 0 . 0 4 0 5 4 - 5 9 m o n t h s * * 5 ( 5 / 6 ) 8 9 . 8 0 ( 2 0 .2 5 ) 7 ( 7 / 7 ) 1 1 9 . 8 6 ( 3 . 1 3 ) 3 .9 3 7 0 .0 0 3 6 0 - 6 5 m o n t h s 5 ( 5 / 7 ) 7 1 . 0 0 ( 4 3 . 8 4 ) 6 ( 6 / 6 ) 1 1 5 . 8 3 ( 5 .6 4 ) 2 .2 7 1 0 . 0 8 4 6 6 - 7 1 m o n t h s * 5 ( 5 / 5 ) 7 9 . 6 0 ( 2 3 . 0 2 ) 1 0 ( 1 0 / 1 0 ) 1 1 5 . 0 0 ( 3 . 1 3 ) 3 .4 2 3 0 . 0 2 6 *P< .0 5 . **P< .0 1 . As can be seen, the test had been completed totally independently in all of the subjects without disabilities, with no problems occurring during the procedures of test administration. Conversely, more than half of subjects with autism (i.e. n=19, 51%) demonstrated difficulty completing the test independently. Among these subjects, the researcher could not administer the test on 13 subjects (i.e. 35%), and 6 subjects (i.e. 16%) in this group completed the test with assistances from the supervising adults. In Table 7, the comparison of the group means on raw scores and standard scores in the comparable chronological age level indicated that the autistic subjects scored significantly lower in Chinese Version of PPVT-R than did the subjects with Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 135 normally developing. This finding was not surprising because it is consistent with the conclusion in the literature. In DSM IV (APA, 1994), 75% of individuals with autism had been described as having mental retardation at the moderate retarded level, IQ scored in the range of 35 to 50. A study of language comprehension in autistic children revealed the impairment of overall sentence comprehension in autistic children, as compared with normally developing children (Tager-Flusbrg, 1981). Also, autistic subjects were found to perform poorly on standardized tests of language comprehension among three groups of autistic, aphasic, and mentally handicapped subjects (Paul & Cohen, 1984). A significant delay in language comprehension was the crucial indicator to differentiate high functioning autism from other specific language disorders (Lord, Pickles, DiLavore, & Shulman, 1996; Rutter, Mawhood, & Howlin, 1992). Delays in receptive as well as expressive language were commonly observed in very young children with autism, and were strongly associated with social difficulties in their adulthood (Rutter, Mawhood, & Howlin, 1992). In a series of longitudinal studies, young children with autism at 2 years of age had been examined and had been followed up when they reached 3, 4, and 5 years old, the results showed that autistic children always performed considerably poorer on receptive language understanding than other groups with language delays (Lord, Pickles, DiLavore, & Shulman, 1996). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 136 Although the autistic subjects in this study scored significantly lower on PPVT-R than did the normal subjects, it is worth noting that 10 autistic subjects (i.e., 27%) in this study were eligible to be classified as the average learner (i.e., n=7, standard score=90 to 109), the rapid learner (i.e., n=2, standard score=110 to 124), and the very rapid learner (i.e., n=l, standard score=125 and above), as suggested by the manual (Dunn, 1961). Thus, this result provided the additional support that not every individual with autism has associated features of mental retardation. Research Findings on Research Questions/Hypotheses The research findings on each research question and hypothesis will be reported and described in order. Question 1 Were there any significant differences in play performance, as measured by the Revised Preschool Play Scale (PPS), of Taiwanese boys with autism compared to boys without disabilities, aged 3 to 5 years? Hypothesis 1 Significant differences would exist between boys without disabilities and boys with autism on the mean scores of the PPS and its four dimensions (Space Management, Material Management, Pretense/Symbolic, and Participation). The mean scores and standard deviations on PPS for boys with autism and boys without disabilities for all age groups combined are summarized in Table 8. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 137 T a b l e 8 : M e a n S c o r e s a n d S t a n d a r d D e v i a t i o n s f o r B o y s w i t h A u t i s m a n d B o y s w i t h o u t D i s a b i l i t i e s o n P r e s c h o o l P l a y S c a l e b y C a t e g o r y , D i m e n s i o n , a n d T o t a l P l a y A g e P P S C o m p o n e n t s B o y s w i t h a u t i s m ( N = 3 7 ) M e a n ( S D ) B o y s w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) M e a n ( S D ) T P S p a c e m a n a g e m e n t * * 4 2 . 6 ( 1 3 . 0 ) 5 7 . 0 ( 8 .7 ) - 5 .6 7 1 < 0 .0 0 1 G r o s s m o t o r * 5 4 . 0 ( 1 1 .5 ) 5 9 . 1 ( 1 0 . 7 ) - 2 . 0 5 6 0 .0 4 3 I n t e r e s t * * 3 1 . 3 ( 1 7 .4 ) 5 4 . 9 ( 7 . 6 ) - 7 . 6 1 0 < 0 .0 0 1 M a t e r i a l m a n a g e m e n t * * 4 1 . 0 ( 1 1 . 6 ) 6 0 . 0 ( 7 .8 ) - 8 . 4 1 9 < 0 .0 0 1 M a n i p u l a t i o n * * 4 0 . 7 ( 1 6 . 0 ) 5 8 . 9 ( 1 1 . 2 ) - 5 . 7 8 4 < 0 .0 0 1 C o n s t r u c t i o n * * 2 8 . 1 ( 1 3 . 9 ) 5 4 . 0 ( 1 0 . 7 ) - 9 . 2 2 5 < 0 . 0 0 1 P u r p o s e * * 2 7 . 4 ( 1 9 . 9 ) 5 4 . 9 ( 1 1 . 0 ) - 7 . 4 5 9 < 0 . 0 0 1 A t t e n t i o n 6 7 . 8 ( 1 4 . 4 ) 7 2 . 0 ( 0 . 0 ) - 1 . 7 7 9 0 . 0 8 4 P r e t e n s e / S y m b o l i c * * 2 0 . 1 ( 1 1 . 0 ) 5 2 . 5 ( 1 2 . 7 ) - 1 2 . 0 2 0 < 0 . 0 0 1 I m i t a t i o n * * 2 1 . 4 ( 1 1 . 5 ) 5 2 . 7 ( 1 2 . 4 ) - 1 1 . 5 6 9 < 0 . 0 0 1 D r a m a t i z a t i o n * * 1 8 . 8 ( 1 0 .8 ) 5 2 . 3 ( 1 3 . 1 ) - 1 2 . 3 1 5 < 0 . 0 0 1 P a r t i c i p a t i o n * * 2 2 . 1 ( 1 0 . 3 ) 5 3 . 0 ( 1 2 . 4 ) - 1 1 . 9 1 5 < 0 . 0 0 1 T y p e * * 2 1 . 9 ( 1 4 . 8 ) 5 7 . 9 ( 1 2 . 1 ) - 1 1 . 8 7 3 < 0 . 0 0 1 C o o p e r a t i o n * * 2 6 . 0 ( 1 2 . 3 ) 5 4 . 6 ( 1 4 . 0 ) - 9 . 6 3 0 < 0 . 0 0 1 H u m o r ** 1 6 . 2 ( 5 .6 ) 4 6 . 7 ( 1 3 . 3 ) - 1 3 . 5 5 7 < 0 .0 0 1 L a n g u a g e * * 2 4 . 3 ( 1 5 . 2 ) 5 2 . 7 ( 1 3 . 5 ) - 8 . 7 8 9 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) * * 3 1 . 5 ( 1 0 . 7 ) 5 5 . 6 ( 9 . 6 ) - 1 0 . 5 4 7 < 0 . 0 0 1 *P< .0 5 . * * P < .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 138 It is clear from the data, that the group with autism had significantly lower scores on PPS total play age and its four dimensions than the group without disabilities. The PPS dimensions that contributed significantly to the differences between groups, in the order of magnitude of differences, were the Pretense/Symbolic score, Participation score, Material Management score, and Space Management score. Further investigation and comparisons of the scores, for each age group of autistic and normal subjects are summarized in Tables 9, 10, and 11. The results were consistent with findings from the overall analyses on Table 8, that the autistic group scored significantly lower on all five play scores (i.e., PPS total play age and its four dimensions) across three age groups. In Tables 9, 10, and 11, analyses also indicated that the score on Participation dimension showed the greatest magnitude of the difference between the autism group and the normal group followed by the score on Pretense/Symbolic, Material Management, and Space Management dimension, across the three age groups. Interestingly, the greatest difference of PPS total score between autism and normal subjects was found in the age group of 4-5 years while the age group of 5-6 years was in the second and age group of 3-4 years was in the last place. Hence, across three age groups, almost all of the greatest difference on scores between autism and normal groups occurred in age group of 4-5 years, on four play dimensions and on ten play categories. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 139 T a b l e 9 : M e a n S c o r e s a n d S t a n d a r d D e v i a t i o n s f o r B o y s w i t h A u t i s m a n d B o y s w i t h o u t D i s a b i l i t i e s , G r o u p o f A g e s 3 - 4 Y e a r s , o n P r e s c h o o l P l a y S c a l e b y C a t e g o r y , D i m e n s i o n , a n d T o t a l P l a y A g e P P S C o m p o n e n t s B o y s w i t h a u t i s m ( n = 1 0 ) M e a n ( S D ) B o y s w i t h o u t d i s a b i l i t i e s (n=13) M e a n ( S D ) T P S p a c e m a n a g e m e n t * 3 7 . 2 ( 1 0 .2 ) 4 8 . 0 ( 5 . 5 ) - 3 . 0 2 5 0 . 0 1 0 G r o s s m o t o r 4 5 . 0 ( 6 . 5 ) 4 8 . 0 ( 6 . 9 ) - 1 . 0 5 8 0 . 3 0 2 I n t e r e s t * * 2 9 . 4 ( 1 7 . 3 ) 4 8 . 0 ( 4 . 9 ) - 3 . 2 9 8 0 . 0 0 8 M a t e r i a l m a n a g e m e n t * * 3 8 . 9 ( 9 . 5 ) 5 2 . 6 ( 5 .8 ) - 4 . 2 8 7 < 0 . 0 0 1 M a n i p u l a t i o n * * 3 4 . 2 ( 1 1 . 3 ) 4 8 . 0 ( 8 . 5 ) - 3 . 3 4 6 0 .0 0 3 C o n s t r u c t i o n * * 2 4 . 6 ( 1 3 . 4 ) 4 5 . 2 ( 8 . 7 ) - 4 . 4 7 3 < 0 .0 0 1 P u r p o s e * * 2 4 . 6 ( 1 7 . 5 ) 4 5 . 2 ( 8 . 7 ) - 3 .4 1 1 0 .0 0 5 A t t e n t i o n 7 2 . 0 ( 0 . 0 ) 7 2 . 0 ( 0 .0 ) - - P r e t e n s e / S y m b o l i c * * 1 8 . 9 ( 9 .3 ) 4 5 . 5 ( 1 1 . 6 ) - 5 . 9 1 7 < 0 . 0 0 1 I m i t a t i o n * * 2 1 . 0 ( 1 0 . 3 ) 4 5 . 7 ( 1 1 . 4 ) - 5 . 3 7 5 < 0 . 0 0 1 D r a m a t i z a t i o n * * 1 6 . 8 ( 8 .9 ) 4 5 . 2 ( 1 1 . 9 ) - 6 . 3 1 5 < 0 .0 0 1 P a r t i c i p a t i o n * * 2 0 . 0 ( 7 . 8 ) 4 2 . 0 ( 9 . 2 ) - 6 . 0 7 9 < 0 .0 0 1 T y p e * * 2 1 . 0 ( 1 1 . 4 ) 4 7 . 5 ( 1 0 . 5 ) - 5 . 7 8 3 < 0 .0 0 1 C o o p e r a t i o n * * 2 2 . 2 ( 7 . 5 ) 4 2 . 0 ( 9 . 5 ) - 5 . 4 1 4 < 0 .0 0 1 H u m o r ** 1 6 . 8 ( 6 .2 ) 3 6 . 5 ( 1 0 . 5 ) - 5 . 5 9 2 < 0 .0 0 1 L a n g u a g e * * 1 9 . 8 ( 1 1 .7 ) 4 2 . 0 ( 1 1 . 0 ) - 4 . 6 8 3 < 0 .0 0 1 P P S ( T o t a l P l a y A g e ) * * 2 8 . 7 ( 8 . 6 ) 4 7 . 0 ( 6 . 7 ) - 5 . 7 4 4 < 0 .0 0 1 *P < .0 5 . * * P < .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 140 T a b l e 1 0 : M e a n S c o r e s a n d S t a n d a r d D e v i a t i o n s f o r B o y s w i t h A u t i s m a n d B o y s w i t h o u t D i s a b i l i t i e s , G r o u p o f A g e s 4 - 5 Y e a r s , o n P r e s c h o o l P l a y S c a l e b y C a t e g o r y , D i m e n s i o n , a n d T o t a l P l a y A g e P P S C o m p o n e n t s B o y s w i t h a u t i s m ( n = 1 5 ) M e a n ( S D ) B o y s w i t h o u t d i s a b i l i t i e s ( n = 1 3 ) M e a n ( S D ) T P S p a c e m a n a g e m e n t ** 3 8 . 0 ( 8 .4 ) 5 5 . 4 ( 5 .0 ) - 6 .5 3 1 < 0 .0 0 1 G r o s s m o t o r 5 2 . 0 ( 8 .7 ) 5 7 . 2 ( 5 .3 ) - 1 . 9 5 5 0 .0 6 3 I n t e r e s t * * 2 4 . 0 ( 1 1 . 1 ) 5 3 . 5 ( 6 .2 ) - 8 . 4 8 7 < 0 .0 0 1 M a t e r i a l m a n a g e m e n t * * 3 6 . 1 ( 8 .8 ) 5 7 . 7 ( 3 .3 ) - 8 .3 8 1 < 0 .0 0 1 M a n i p u l a t i o n * * 3 6 . 0 ( 1 2 . 0 ) 5 6 . 3 ( 5 .8 ) - 5 . 8 2 5 < 0 . 0 0 1 C o n s t r u c t i o n ** 2 1 . 6 ( 8 . 7 ) 5 0 . 8 ( 5 . 3 ) - 1 0 . 4 9 8 < 0 .0 0 1 P u r p o s e * * 1 8 . 4 ( 1 3 .1 ) 5 1 . 7 ( 5 . 8 ) - 8 . 4 5 4 < 0 . 0 0 1 A t t e n t i o n 6 8 . 4 ( 1 3 . 9 ) 7 2 . 0 ( 0 . 0 ) - 0 . 9 2 9 0 . 3 6 2 P r e t e n s e / S y m b o l i c * * 1 6 . 2 ( 6 .0 ) 4 6 . 6 ( 6 . 9 ) - 1 2 . 5 1 5 < 0 . 0 0 1 I m i t a t i o n * * 1 7 . 2 ( 7 .1 ) 4 7 . 1 ( 5 . 9 ) - 1 1 . 9 5 3 < 0 . 0 0 1 D r a m a t i z a t i o n * * 1 5 . 2 ( 5 .0 ) 4 6 . 2 ( 7 . 9 ) - 1 2 . 5 7 0 < 0 .0 0 1 P a r t i c i p a t i o n * * 1 7 . 1 ( 5 .0 ) 4 8 . 8 ( 6 . 6 ) - 1 4 . 4 6 2 < 0 . 0 0 1 T y p e * * 1 6 . 0 ( 7 .8 ) 5 5 . 4 ( 7 . 8 ) - 1 3 . 3 7 1 < 0 . 0 0 1 C o o p e r a t i o n * * 2 0 . 0 ( 9 . 5 ) 5 0 . 3 ( 8 . 3 ) - 8 . 8 9 4 < 0 . 0 0 1 H u m o r ** 1 4 . 4 ( 3 .8 ) 4 2 . 5 ( 1 0 . 2 ) - 9 . 3 4 4 < 0 . 0 0 1 L a n g u a g e * * 1 8 . 0 ( 8 .5 ) 4 7 . 1 ( 5 . 9 ) - 1 0 . 6 1 9 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) * * 2 6 . 9 ( 6 . 2 ) 5 2 . 1 ( 4 . 1 ) - 1 2 . 4 7 3 < 0 . 0 0 1 * P < .0 5 . * * P < . 0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 141 T a b l e 1 1 : M e a n S c o r e s a n d S t a n d a r d D e v i a t i o n s f o r B o y s w i t h A u t i s m a n d B o y s w i t h o u t D i s a b i l i t i e s , G r o u p o f A g e s 5 - 6 Y e a r s , o n P r e s c h o o l P l a y S c a l e b y C a t e g o r y , D i m e n s i o n , a n d T o t a l P l a y A g e P P S C o m p o n e n t s B o y s w i t h a u t i s m ( n = 1 2 ) M e a n ( S D ) B o y s w i t h o u t d i s a b i l i t i e s ( n = 1 6 ) M e a n ( S D ) T P S p a c e m a n a g e m e n t * 5 3 . 0 ( 1 4 .4 ) 6 5 . 6 ( 3 .4 ) - 2 . 9 6 7 0 . 0 1 2 G r o s s m o t o r 6 4 . 0 ( 1 0 .7 ) 6 9 . 8 ( 4 . 8 ) - 1 . 7 4 0 0 .1 0 3 I n t e r e s t * * 4 2 . 0 ( 1 9 . 8 ) 6 1 . 5 ( 4 . 1 ) - 3 . 3 5 5 0 . 0 0 6 M a t e r i a l m a n a g e m e n t * * 4 8 . 9 ( 1 2 . 8 ) 6 7 . 7 ( 3 . 8 ) - 4 . 9 4 9 < 0 .0 0 1 M a n i p u l a t i o n * * 5 2 . 0 ( 1 8 .3 ) 6 9 . 8 ( 4 . 8 ) - 3 . 2 7 0 0 . 0 0 7 C o n s t r u c t i o n * * 3 9 . 0 ( 1 3 .7 ) 6 3 . 8 ( 7 . 2 ) - 5 . 7 0 7 < 0 .0 0 1 P u r p o s e * * 4 1 . 0 ( 2 2 . 4 ) 6 5 . 3 ( 6 . 2 ) - 3 . 6 4 5 0 .0 0 3 A t t e n t i o n 6 3 . 5 ( 1 9 .9 ) 7 2 . 0 ( 0 . 0 ) - 1 . 4 8 0 0 . 1 6 7 P r e t e n s e / S y m b o l i c * * 2 6 . 0 ( 1 4 . 9 ) 6 3 . 0 ( 1 0 . 3 ) - 7 . 7 9 2 < 0 .0 0 1 I m i t a t i o n * * 2 7 . 0 ( 1 5 . 0 ) 6 3 . 0 ( 1 0 . 3 ) - 7 . 5 3 7 < 0 .0 0 1 D r a m a t i z a t i o n * * 2 5 . 0 ( 1 4 . 9 ) 6 3 . 0 ( 1 0 . 3 ) - 8 . 0 0 3 < 0 . 0 0 1 P a r t i c i p a t i o n ** 3 0 . 1 ( 1 2 . 6 ) 6 2 . 3 ( 6 . 2 ) - 8 .8 6 1 < 0 . 0 0 1 T y p e * * 3 0 . 0 ( 2 0 . 3 ) 6 8 . 3 ( 7 . 2 ) - 6 . 2 3 6 < 0 . 0 0 1 C o o p e r a t i o n ** 3 6 . 5 ( 1 2 . 1 ) 6 8 . 3 ( 7 . 2 ) - 8 . 6 5 4 < 0 . 0 0 1 H u m o r * * 1 8 , 0 ( 6 .8 ) 5 8 . 5 ( 7 . 4 ) - 1 4 . 8 1 7 < 0 . 0 0 1 L a n g u a g e * * 3 6 . 0 ( 1 8 . 3 ) 6 6 . 0 ( 7 . 6 ) - 5 . 3 5 2 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) * * 3 9 . 5 ( 1 2 . 7 ) 6 5 . 4 ( 5 . 1 ) - 6 . 6 6 4 < 0 . 0 0 1 *P< .0 5 . * * P < .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 142 These findings revealed that the magnitude of the difference on the play scores between the group with autism and the group without disabilities did not increase with the chronological age groups. Many researchers believed that the impairment in children with autism might improve gradually with age and maturation (DeMyer et ah, 1973; Lord et ah, 1996; Lotter, 1974 & 1978; Rutter, 1970). Thus, this researcher believes that although individuals with autism might demonstrate difficulties in many areas almost lifelong, their performance should not be considered as static. The analyses revealed that the mean scores of the two groups (i.e., boys with autism and boys without disabilities) were significantly different on the PPS total score and its four dimensions. Hypothesis 1 was supported. Question 2 Were there any significant differences between the developmental play age and chronological age of the children in each group? Hypothesis 2 Significant differences would exist between the developmental play age and chronological age, only in the group of boys with autism and not in the group of boys without disabilities. The play of autistic and normal children was investigated further by comparing the mean age scores on PPS with their mean chronological ages. Table 12 presents the mean age score on PPS for all age groups combined of autistic and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 143 normal subjects and their respective mean chronological ages. As can be seen in Table 12, the mean score of autistic children on developmental play age (i.e., PPS total play age) was significantly lower than their mean chronological age ip <0.01). Statistically, the mean of PPS total play age and the mean of chronological age was not different in the group of children without disabilities. Thus, the Hypothesis 2 was supported. In the group of the subjects with autism, their mean scores on the PPS four dimensions were found to be significantly lower when compared with their mean chronological age. However, interestingly enough, they had extremely high scores on Attention category. In fact, the mean Attention score was higher than chronological age for the total group with autism; and the difference between the mean score on this category and their chronological age reached significance (p < 0.01) (Table 12). In contrast, the group of normal subjects obtained higher age scores on the Space Management dimension and the Material Management dimension, as compared with their chronological age, and these differences reached significance ip < 0.01) because the play age scores were higher than chronological for these dimensions. Even though they scored lower on the Pretense/Symbolic dimension and Participation dimension than their chronological age, the differences were not significant. It is interesting to find that their age score on the Humor category was found to be significantly lower than their chronological age. Also, it is worth noting Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 144 that every normal subject in this study obtained the highest score on the Attention category, therefore, they had the ceiling level of mean score on this category. T a b l e 1 2 : D i f f e r e n c e B e t w e e n C h r o n o l o g i c a l A g e a n d P e r f o r m a n c e o n P r e s c h o o l P l a y S c a l e , f o r B o y s w i t h A u t i s m a n d B o y s w i t h o u t D i s a b i l i t i e s , A g e s 3 - 6 Y e a r s B o y s w i t h A u t i s m , A g e s 3 - 6 Y e a r s ( N - 3 7 ) P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) P a i r e d - T P S p a c e m a n a g e m e n t * * 4 2 . 7 ( 1 3 . 0 ) 5 4 . 2 ( 9 . 5 ) 6 . 2 3 0 < 0 .0 0 1 G r o s s m o t o r 5 4 . 0 ( 1 1 .5 ) 5 4 . 2 ( 9 . 5 ) 0.111 0 .9 1 2 I n t e r e s t * * 3 1 . 3 ( 1 7 .4 ) 5 4 . 2 ( 9 . 5 ) 8 . 4 6 0 < 0 .0 0 1 M a t e r i a l m a n a g e m e n t * * 4 1 . 0 ( 1 1 . 6 ) 5 4 . 2 ( 9 . 5 ) 6 . 7 9 7 < 0 .0 0 1 M a n i p u l a t i o n * * 4 0 . 7 ( 1 6 . 0 ) 5 4 . 2 ( 9 . 5 ) 5 . 7 5 4 < 0 .0 0 1 C o n s t r u c t i o n * * 2 8 . 1 ( 1 3 . 9 ) 5 4 . 2 ( 9 . 5 ) 1 2 .8 0 9 < 0 .0 0 1 P u r p o s e * * 2 7 . 4 ( 1 9 . 9 ) 5 4 . 2 ( 9 . 5 ) 8 . 8 8 6 < 0 .0 0 1 A t t e n t i o n * * 6 7 . 8 ( 1 4 .4 ) 5 4 . 2 ( 9 . 5 ) - 4 . 2 6 6 < 0 .0 0 1 P r e t e n s e / S y m b o l i c * * 2 0 . 1 ( 1 1 . 0 ) 5 4 . 2 ( 9 . 5 ) 1 6 . 0 9 9 < 0 .0 0 1 I m i t a t i o n * * 2 1 . 4 ( 1 1 . 5 ) 5 4 . 2 ( 9 . 5 ) 1 4 . 6 8 4 < 0 .0 0 1 D r a m a t i z a t i o n * * 1 8 . 8 ( 1 0 .8 ) 5 4 . 2 ( 9 . 5 ) 1 7 .3 5 5 < 0 .0 0 1 P a r t i c i p a t i o n * * 2 2 . 1 ( 1 0 . 3 ) 5 4 . 2 ( 9 . 5 ) 1 8 .1 5 7 < 0 .0 0 1 T y p e * * 2 1 . 9 ( 1 4 . 8 ) 5 4 . 2 ( 9 . 5 ) 1 3 .0 3 9 < 0 .0 0 1 C o o p e r a t i o n * * 2 6 . 0 ( 1 2 . 3 ) 5 4 . 2 ( 9 . 5 ) 1 4 . 3 6 9 < 0 .0 0 1 H u m o r * * 1 6 . 2 ( 5 .6 ) 5 4 . 2 ( 9 . 5 ) 2 2 . 0 6 9 < 0 .0 0 1 L a n g u a g e * * 2 4 . 3 ( 1 5 . 2 ) 5 4 . 2 ( 9 . 5 ) 1 3 .2 6 3 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) * * 3 1 . 5 ( 1 0 . 8 ) 5 4 . 2 ( 9 . 5 ) 1 2 . 6 6 0 < 0 .0 0 1 *P< .0 5 . **P < .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 145 Table 12 (continued) B o y s w i t h o u t D i s a b i l i t i e s , A g e s 3 - 6 Y e a r s ( N = 4 2 ) P a i r e d - T P P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) S p a c e m a n a g e m e n t * * 5 7 . 0 ( 8 . 7 ) 5 4 . 4 ( 1 0 .1 ) - 3 . 3 8 5 0 . 0 0 2 G r o s s m o t o r * * 5 9 . 1 ( 1 0 .7 ) 5 4 . 4 ( 1 0 .1 ) - 5 . 7 6 9 < 0 . 0 0 1 I n t e r e s t 5 4 . 9 ( 7 . 6 ) 5 4 . 4 ( 1 0 .1 ) - 0 . 4 9 6 0 .6 2 3 M a t e r i a l m a n a g e m e n t * * 5 9 . 9 ( 7 .8 ) 5 4 . 4 ( 1 0 . 1 ) - 7 . 1 3 4 < 0 . 0 0 1 M a n i p u l a t i o n * * 5 8 . 9 ( 1 1 . 2 ) 5 4 . 4 ( 1 0 . 1 ) - 5 . 6 1 9 < 0 . 0 0 1 C o n s t r u c t i o n 5 4 . 0 ( 1 0 . 7 ) 5 4 . 4 ( 1 0 . 1 ) 0 . 3 4 6 0 .7 3 1 P u r p o s e 5 4 . 9 ( 1 1 . 0 ) 5 4 . 4 ( 1 0 . 1 ) - 0 . 4 6 8 0 .6 4 3 A t t e n t i o n * * 7 2 . 0 ( 0 . 0 ) 5 4 . 4 ( 1 0 . 1 ) - 1 1 . 3 7 1 < 0 . 0 0 1 P r e t e n s e / S y m b o l i c 5 2 . 5 ( 1 2 . 7 ) 5 4 . 4 ( 1 0 . 1 ) 1 .2 4 3 0 .2 2 1 I m i t a t i o n 5 2 . 7 ( 1 2 . 4 ) 5 4 . 4 ( 1 0 . 1 ) 1 .1 3 3 0 . 2 6 4 D r a m a t i z a t i o n 5 2 . 3 ( 1 3 . 1 ) 5 4 . 4 ( 1 0 . 1 ) 1 .3 4 0 0 . 1 8 8 P a r t i c i p a t i o n 5 3 . 0 ( 1 2 . 4 ) 5 4 . 4 ( 1 0 . 1 ) 1 .2 7 7 0 . 2 0 9 T y p e * * 5 7 . 9 ( 1 2 . 1 ) 5 4 . 4 ( 1 0 . 1 ) - 2 . 8 3 3 0 . 0 0 7 C o o p e r a t i o n 5 4 . 6 ( 1 4 . 0 ) 5 4 . 4 ( 1 0 . 1 ) - 0 . 1 6 6 0 . 8 6 9 H u m o r * * 4 6 . 7 ( 1 3 . 3 ) 5 4 . 4 ( 1 0 . 1 ) 5 . 6 3 0 < 0 . 0 0 1 L a n g u a g e 5 2 . 7 ( 1 3 . 5 ) 5 4 . 4 ( 1 0 . 1 ) 1 .2 5 4 0 . 2 1 7 P P S ( T o t a l P l a y A g e ) 5 5 . 6 ( 9 . 6 ) 5 4 . 4 ( 1 0 . 1 ) - 1 . 5 2 7 0 . 1 3 5 *P < ,0 5 . * * P < . 0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 146 Tables 13, 14, and 15 present the comparison of chronological age and mean age scores on PPS for each of the age groups for the autistic and normal groups. Mostly, the results were consistent with the findings shown on Table 12 as an overall analysis. The specific comparisons and findings for each age group will be described as follows. For the group of 3-4 year age, with the exception of Gross Motor and Attention categories, the subjects with autism obtained lower age scores on PPS, as compared with their mean chronological age, and 12 out of 15 of these differences reached significance (p<0.05) (see Table 13). In contrast, the normal subjects obtained higher age scores on 13 of 17 scores, as compared with their mean chronological age, and 7 of them reached significant level (p<0.05). Among the 4 categories scored lower than the chronological age in the group of normal subjects, only the difference on Humor score was found statistically significant (p<0.05) (see Table 13). Generally, in the three age groups, the greatest difference between chronological age and the age scores on PPS was found in the group of 4-5 year age, for both groups of autistic and normal subjects (see Table 14). The data revealed that all age scores on PPS, except the one on Gross Motor category, differed significantly from the chronological age in the group of autistic subjects, and only the score on Attention category was reported higher than their chronological age, while other scores were much lower to reach significance (p<0.01). For the group of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 147 normal subjects, the subjects had 7 scores higher than their chronological age in this age group, whereas 13 scores in the group of 3-4 years were revealed higher than subject’s chronological age, and 11 scores were showed higher than subjects’ chronological age in the group of 5-6 years, respectively. Importantly, the scores on Pretense/symbolic dimension, on the categories of Imitation, Dramatization, Humor, Language (p<0.01), and on Participation dimension (p<0.05) were found significantly lower than the chronological age in this age group of normal subjects (see Table 14). For the group of ages 5-6 years, with the exception of Gross Motor and Attention categories, the subjects with autism obtained lower age scores on PPS, compared with their mean chronological age, and all these 15 differences were statistically significant (p<0.05) (see Table 15). Conversely, the results showed that the normal subjects obtained higher age scores on 11 of 17 scores, as compared with their mean chronological age, and 4 of them reached significance (p<0.01). However, there were 6 categories in the group of normal subjects scored lower than the chronological age, 2 of them, Interest and Humor categories, were found statistically significant (p<0.01) (see Table 15). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 148 Table 13: Difference Between Chronological Age and Performance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Group of Ages 3-4 Years. B o y s w i t h A u t i s m , G r o u p o f A g e s 3 - 4 Y e a r s ( n = T 0 ) P a i r e d - T P P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) S p a c e m a n a g e m e n t 3 7 . 2 ( 1 0 . 2 ) 4 2 . 7 ( 3 . 1 ) 2 . 0 8 5 0 .0 6 7 G r o s s m o t o r 4 5 . 0 ( 6 .5 ) 4 2 . 7 ( 3 . 1 ) - 1 . 4 8 4 0 . 1 7 2 I n t e r e s t * 2 9 . 4 ( 1 7 . 3 ) 4 2 . 7 ( 3 . 1 ) 2 .6 7 1 0 . 0 2 6 M a t e r i a l m a n a g e m e n t 3 8 . 9 ( 9 .5 ) 4 2 . 7 ( 3 . 1 ) 1 .6 9 7 0 . 2 2 7 M a n i p u l a t i o n 3 4 . 2 ( 1 1 . 3 ) 4 2 . 7 ( 3 . 1 ) 2 . 2 1 7 0 .0 5 4 C o n s t r u c t i o n * * 2 4 . 6 ( 1 3 . 4 ) 4 2 . 7 ( 3 . 1 ) 4 . 3 7 4 0 , 0 0 2 P u r p o s e * * 2 4 . 6 ( 1 7 . 5 ) 4 2 . 7 ( 3 . 1 ) 3 . 4 3 4 0 .0 0 7 A t t e n t i o n ** 7 2 . 0 ( 0 .0 ) 4 2 . 7 ( 3 . 1 ) - 3 0 . 3 1 0 < 0 .0 0 1 P r e t e n s e / S y m b o l i c * * 1 8 . 9 ( 9 .3 ) 4 2 . 7 ( 3 . 1 ) 8 . 2 3 6 < 0 .0 0 1 I m i t a t i o n * * 2 1 . 0 ( 1 0 . 3 ) 4 2 . 7 ( 3 . 1 ) 6 . 6 0 3 < 0 .0 0 1 D r a m a t i z a t i o n * * 1 6 . 8 ( 8 .9 ) 4 2 . 7 ( 3 . 1 ) 9 . 7 0 6 < 0 .0 0 1 P a r t i c i p a t i o n * * 1 9 . 9 ( 7 .8 ) 4 2 . 7 ( 3 . 1 ) 1 0 .6 7 7 < 0 .0 0 1 T y p e * * 2 1 . 0 ( 1 1 . 4 ) 4 2 . 7 ( 3 . 1 ) 6 .6 0 3 < 0 .0 0 1 C o o p e r a t i o n * * 2 2 . 2 ( 7 . 5 ) 4 2 . 7 ( 3 . 1 ) 9 . 7 4 2 < 0 .0 0 1 H u m o r * * 1 6 . 8 ( 6 .2 ) 4 2 . 7 ( 3 . 1 ) 1 4 .6 6 0 < 0 . 0 0 1 L a n g u a g e * * 1 9 . 8 ( 1 1 .7 ) 4 2 . 7 ( 3 . 1 ) 6 . 7 4 7 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) * * 2 8 . 7 ( 8 .6 ) 4 2 . 7 ( 3 . 1 ) 5 . 6 7 0 < 0 . 0 0 1 *P < .0 5 . **P< .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 149 Table 13 (continued) B o y s w i t h o u t D i s a b i l i t i e s , G r o u p o f A g e s 3 - 4 Y e a r s ( n = 1 3 ) P a i r e d - T P P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) S p a c e m a n a g e m e n t * * 4 8 . 0 ( 5 . 5 ) 4 2 . 3 ( 3 . 3 ) - 4 . 8 7 4 < 0 .0 0 1 G r o s s m o t o r * * 4 8 . 0 ( 6 .9 ) 4 2 . 3 ( 3 . 3 ) - 3 . 7 0 2 0 .0 0 3 I n t e r e s t * * 4 8 . 0 ( 4 .9 ) 4 2 . 3 ( 3 . 3 ) - 5 . 0 1 8 < 0 .0 0 1 M a t e r i a l m a n a g e m e n t * * 5 2 . 6 ( 5 .8 ) 4 2 . 3 ( 3 . 3 ) - 8 . 7 0 4 < 0 .0 0 1 M a n i p u l a t i o n * 4 8 . 0 ( 8 .5 ) 4 2 . 3 ( 3 . 3 ) - 3 . 0 0 2 0 .0 1 1 C o n s t r u c t i o n 4 5 . 2 ( 8 . 7 ) 4 2 . 3 ( 3 . 3 ) - 1 . 5 4 4 0 . 1 4 8 P u r p o s e 4 5 . 2 ( 8 . 7 ) 4 2 . 3 ( 3 . 3 ) - 1 .4 0 1 0 . 1 8 6 A t t e n t i o n * * 7 2 . 0 ( 0 .0 ) 4 2 . 3 ( 3 . 3 ) - 3 2 .6 8 1 < 0 .0 0 1 P r e t e n s e / S y m b o l i c 4 5 . 5 ( 1 1 . 6 ) 4 2 . 3 ( 3 . 3 ) - 1 . 0 6 6 0 .3 0 7 I m i t a t i o n 4 5 . 7 ( 1 1 . 4 ) 4 2 . 3 ( 3 . 3 ) - 1 . 1 6 7 0 . 2 6 6 D r a m a t i z a t i o n 4 5 . 2 ( 1 1 . 9 ) 4 2 . 3 ( 3 . 3 ) - 0 . 9 6 4 0 . 3 5 4 P a r t i c i p a t i o n 4 2 . 0 ( 9 . 2 ) 4 2 . 3 ( 3 . 3 ) 0 . 1 4 0 0 .8 9 1 T y p e 4 7 . 5 ( 1 0 . 5 ) 4 2 . 3 ( 3 . 3 ) - 1 . 9 9 7 0 .0 6 9 C o o p e r a t i o n 4 2 . 0 ( 9 . 5 ) 4 2 . 3 ( 3 . 3 ) 0 . 1 1 8 0 . 9 0 8 H u m o r * 3 6 . 5 ( 1 0 . 5 ) 4 2 . 3 ( 3 . 3 ) 2 . 3 1 6 0 , 0 3 9 L a n g u a g e 4 2 . 0 ( 1 0 . 9 ) 4 2 . 3 ( 3 . 3 ) 0 . 1 1 9 0 . 9 0 7 P P S ( T o t a l P l a y A g e ) * * 4 7 . 0 ( 6 . 7 ) 4 2 . 3 ( 3 . 3 ) - 3 .2 8 1 0 . 0 0 7 *P < .0 5 . * * P < . 0 1 , Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 150 Table 14: Difference Between Chronological Age and Performance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Group of Ages 4-5 Years. B o y s w i t h A u t i s m , G r o u p o f A g e s 4 - 5 Y e a r s ( N = 1 5 ) P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) P a i r e d - T P S p a c e m a n a g e m e n t * * 3 8 . 0 ( 8 .4 ) 5 2 . 9 ( 3 .7 ) 6 . 6 0 7 < 0 .0 0 1 G r o s s m o t o r 5 2 . 0 ( 8 .7 ) 5 2 . 9 ( 3 . 7 ) 0 . 4 0 8 0 .6 8 9 I n t e r e s t * * 2 4 . 0 ( 1 1 . 1 ) 5 2 . 9 ( 3 . 7 ) 9 . 7 1 4 < 0 .0 0 1 M a t e r i a l m a n a g e m e n t * * 3 6 . 1 ( 8 . 8 ) 5 2 . 9 ( 3 . 7 ) 6 . 9 6 7 < 0 .0 0 1 M a n i p u l a t i o n * * 3 6 . 0 ( 1 2 . 0 ) 5 2 . 9 ( 3 . 7 ) 5 . 5 4 4 < 0 .0 0 1 C o n s t r u c t i o n ** 2 1 . 6 ( 8 .7 ) 5 2 . 9 ( 3 . 7 ) 1 6 .0 8 0 < 0 .0 0 1 P u r p o s e * * 1 8 . 4 ( 1 3 .1 ) 5 2 . 9 ( 3 . 7 ) 1 0 .0 1 7 < 0 .0 0 1 A t t e n t i o n * * 6 8 . 4 ( 1 3 . 9 ) 5 2 . 9 ( 3 . 7 ) - 3 . 7 5 0 0 . 0 0 2 P r e t e n s e / S y m b o l i c * * 1 6 . 2 ( 5 .9 ) 5 2 . 9 ( 3 . 7 ) 1 8 . 8 8 0 < 0 .0 0 1 I m i t a t i o n * * 1 7 . 2 ( 7 .1 ) 5 2 . 9 ( 3 . 7 ) 1 6 . 2 5 4 < 0 .0 0 1 D r a m a t i z a t i o n ** 1 5 . 2 ( 5 .0 ) 5 2 . 9 ( 3 . 7 ) 2 1 . 7 0 1 < 0 .0 0 1 P a r t i c i p a t i o n * * 1 7 . 1 ( 5 .0 ) 5 2 . 9 ( 3 . 7 ) 2 0 . 4 5 7 < 0 .0 0 1 T y p e * * 1 6 . 0 ( 7 .7 ) 5 2 . 9 ( 3 . 7 ) 1 7 .0 0 2 < 0 .0 0 1 C o o p e r a t i o n ** 2 0 . 0 ( 9 . 5 ) 5 2 . 9 ( 3 . 7 ) 1 1 .2 9 0 < 0 .0 0 1 H u m o r * * 1 4 . 4 ( 3 .8 ) 5 2 . 9 ( 3 . 7 ) 2 5 , 6 0 1 < 0 . 0 0 1 L a n g u a g e * * 1 8 . 0 ( 8 .5 ) 5 2 . 9 ( 3 . 7 ) 1 4 .4 5 2 < 0 .0 0 1 P P S ( T o t a l P l a y A g e ) * * 2 6 . 9 ( 6 . 2 ) 5 2 . 9 ( 3 . 7 ) 1 3 .8 3 0 < 0 .0 0 1 *P< .0 5 . **P< .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 151 Table 14 (continued) B o y s w i t h o u t D i s a b i l i t i e s , G r o u p o f A g e s 4 - 5 Y e a r s ( n = 1 3 ) P a i r e d - T P P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) S p a c e m a n a g e m e n t 5 5 . 4 ( 5 .0 ) 5 3 . 2 ( 2 . 9 ) - 1 . 2 4 3 0 .2 3 8 G r o s s m o t o r 5 7 . 2 ( 5 .3 ) 5 3 . 2 ( 2 . 9 ) - 2 . 0 9 5 0 .0 5 8 I n t e r e s t 5 3 . 5 ( 6 .2 ) 5 3 . 2 ( 2 . 9 ) - 0 . 1 9 4 0 .8 4 9 M a t e r i a l m a n a g e m e n t * * 5 7 . 7 ( 3 .3 ) 5 3 . 2 ( 2 . 9 ) - 3 . 5 7 6 0 . 0 0 4 M a n i p u l a t i o n * 5 6 . 3 ( 5 .8 ) 5 3 . 2 ( 2 . 9 ) - 2 . 2 9 9 0 . 0 4 0 C o n s t r u c t i o n 5 0 . 8 ( 5 .3 ) 5 3 . 2 ( 2 . 9 ) 1 .3 1 0 0 .2 1 5 P u r p o s e 5 1 . 7 ( 5 .8 ) 5 3 . 2 ( 2 . 9 ) 0 . 6 8 6 0 .5 0 5 A t t e n t i o n * * 7 2 . 0 ( 0 .0 ) 5 3 . 2 ( 2 . 9 ) - 2 3 . 3 4 2 < 0 . 0 0 1 P r e t e n s e / S y m b o l i c ** 4 6 . 6 ( 6 . 9 ) 5 3 . 2 ( 2 . 9 ) 3 . 2 8 7 0 . 0 0 6 I m i t a t i o n * * 4 7 . 1 ( 5 . 9 ) 5 3 . 2 ( 2 . 9 ) 3 . 4 9 8 0 . 0 0 4 D r a m a t i z a t i o n * * 4 6 . 2 ( 7 .9 ) 5 3 . 2 ( 2 . 9 ) 3 . 1 0 3 0 . 0 0 9 P a r t i c i p a t i o n * 4 8 . 8 ( 6 . 6 ) 5 3 . 2 ( 2 . 9 ) 2 . 3 3 7 0 . 0 3 8 T y p e 5 5 . 4 ( 7 .8 ) 5 3 . 2 ( 2 . 9 ) - 1 . 0 0 7 0 . 3 3 4 C o o p e r a t i o n 5 0 . 3 ( 8 .3 ) 5 3 . 2 ( 2 . 9 ) 1 .2 3 1 0 . 2 4 2 H u m o r * * 4 2 . 5 ( 1 0 . 2 ) 5 3 . 2 ( 2 . 9 ) 3 . 8 6 7 0 . 0 0 2 L a n g u a g e * * 4 7 . 1 ( 5 . 9 ) 5 3 . 2 ( 2 . 9 ) 3 . 2 5 7 0 . 0 0 7 P P S ( T o t a l P l a y A g e ) 5 2 . 1 ( 4 .1 ) 5 3 . 2 ( 2 . 9 ) 0 . 7 3 9 0 . 4 7 4 *P< .0 5 . **p< .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 152 Table 15: Difference Between Chronological Age and Perform ance on Preschool Play Scale, for Boys with Autism and Boys without Disabilities, Group of Ages 5-6 Years. B o y s w i t h A u t i s m , G r o u p o f A g e s 5 - 6 Y e a r s ( n = 1 2 ) P a i r e d - T P P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) S p a c e m a n a g e m e n t * 5 3 . 0 ( 1 4 . 4 ) 6 2 . 3 ( 3 .5 ) 2 .9 3 1 0 . 0 1 4 G r o s s m o t o r 6 4 . 0 ( 1 0 . 7 ) 6 2 . 3 ( 3 .5 ) - 0 . 3 8 0 0 .7 1 1 I n t e r e s t * * 4 2 . 0 ( 1 9 . 8 ) 6 2 . 3 ( 3 . 5 ) 4 . 1 3 8 0 . 0 0 2 M a t e r i a l m a n a g e m e n t * * 4 8 . 9 ( 1 2 . 8 ) 6 2 . 3 ( 3 . 5 ) 4 . 4 4 3 0 .0 0 1 M a n i p u l a t i o n * 5 2 . 0 ( 1 8 . 3 ) 6 2 . 3 ( 3 .5 ) 2 .5 4 5 0 . 0 2 7 C o n s t r u c t i o n * * 3 9 . 0 ( 1 3 . 7 ) 6 2 . 3 ( 3 . 5 ) 6 .5 1 3 < 0 .0 0 1 P u r p o s e * * 4 1 . 0 ( 2 2 . 4 ) 6 2 . 3 ( 3 . 5 ) 3 . 8 1 0 0 .0 0 3 A t t e n t i o n 6 3 . 5 ( 1 9 . 9 ) 6 2 . 3 ( 3 .5 ) - 0 . 2 9 7 0 . 7 7 2 P r e t e n s e / S y m b o l i c * * 2 6 . 0 ( 1 4 . 9 ) 6 2 . 3 ( 3 . 5 ) 8 .3 3 1 < 0 .0 0 1 I m i t a t i o n * * 2 7 . 0 ( 1 5 . 0 ) 6 2 . 3 ( 3 . 5 ) 8 . 1 2 7 < 0 .0 0 1 D r a m a t i z a t i o n * * 2 5 . 0 ( 1 4 . 9 ) 6 2 . 3 ( 3 . 5 ) 8 .4 6 5 < 0 . 0 0 1 P a r t i c i p a t i o n * * 3 0 . 1 ( 1 2 . 6 ) 6 2 . 3 ( 3 . 5 ) 9 . 2 3 7 < 0 .0 0 1 T y p e * * 3 0 . 0 ( 2 0 . 3 ) 6 2 . 3 ( 3 . 5 ) 5 .9 4 1 < 0 . 0 0 1 C o o p e r a t i o n * * 3 6 . 5 ( 1 2 . 1 ) 6 2 . 3 ( 3 . 5 ) 7 .3 5 3 < 0 .0 0 1 H u m o r * * 1 8 . 0 ( 6 .8 ) 6 2 . 3 ( 3 . 5 ) 2 0 . 7 2 3 < 0 .0 0 1 L a n g u a g e * * 3 6 . 0 ( 1 8 . 3 ) 6 2 . 3 ( 3 . 5 ) 5 .5 9 9 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) * * 3 9 . 5 ( 1 2 . 7 ) 6 2 . 3 ( 3 . 5 ) 6 .7 0 8 < 0 . 0 0 1 *P < .0 5 . **P < .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 153 Table 15 (continued) B o y s w i t h o u t D i s a b i l i t i e s , G r o u p o f A g e s 5 - 6 Y e a r s ( n = 1 6 ) P a i r e d - T P P P S C o m p o n e n t s S c o r e s o n P P S M e a n ( S D ) C h r o n o l o g i c a l A g e M e a n ( S D ) S p a c e m a n a g e m e n t 6 5 . 6 ( 3 .4 ) 6 5 . 1 ( 3 .2 ) - 0 . 6 5 9 0 . 5 2 0 G r o s s m o t o r * * 6 9 . 8 ( 4 .8 ) 6 5 . 1 ( 3 .2 ) - 4 .9 7 1 < 0 . 0 0 1 I n t e r e s t * * 6 1 . 5 ( 4 .1 ) 6 5 . 1 ( 3 .2 ) 3 . 1 6 0 0 . 0 0 6 M a t e r i a l m a n a g e m e n t ** 6 7 . 7 ( 3 .8 ) 6 5 . 1 ( 3 .2 ) - 3 . 4 8 3 0 .0 0 3 M a n i p u l a t i o n * * 6 9 . 8 ( 4 .8 ) 6 5 . 1 ( 3 .2 ) - 4 .9 7 1 < 0 . 0 0 1 C o n s t r u c t i o n 6 3 . 8 ( 7 .2 ) 6 5 . 1 ( 3 .2 ) 0 . 9 1 4 0 .3 7 5 P u r p o s e 6 5 . 3 ( 6 .2 ) 6 5 . 1 ( 3 . 2 ) - 0 . 0 9 1 0 . 9 2 9 A t t e n t i o n * * 7 2 . 0 ( 0 .0 ) 6 5 . 1 ( 3 .2 ) - 8 . 5 9 0 < 0 . 0 0 1 P r e t e n s e / S y m b o l i c 6 3 . 0 ( 1 0 . 3 ) 6 5 . 1 ( 3 .2 ) 0 . 9 3 3 0 . 3 6 6 I m i t a t i o n 6 3 . 0 ( 1 0 . 3 ) 6 5 . 1 ( 3 . 2 ) 0 . 9 3 3 0 . 3 6 6 D r a m a t i z a t i o n 6 3 . 0 ( 1 0 . 3 ) 6 5 . 1 ( 3 .2 ) 0 . 9 3 3 0 . 3 6 6 P a r t i c i p a t i o n 6 5 . 3 ( 6 . 2 ) 6 5 . 1 ( 3 .2 ) - 0 . 0 8 0 0 . 9 3 7 T y p e 6 8 . 3 ( 7 . 2 ) 6 5 . 1 ( 3 . 2 ) - 1 . 7 9 2 0 . 0 9 3 C o o p e r a t i o n 6 8 . 3 ( 7 . 2 ) 6 5 . 1 ( 3 . 2 ) - 1 . 7 9 2 0 . 0 9 3 H u m o r * * 5 8 . 5 ( 7 . 4 ) 6 5 . 1 ( 3 . 2 ) 3 .6 1 1 0 . 0 0 3 L a n g u a g e 6 6 . 0 ( 7 . 6 ) 6 5 . 1 ( 3 . 2 ) - 0 . 4 3 0 0 . 6 7 3 P P S ( T o t a l P l a y A g e ) 6 5 . 4 ( 5 . 1 ) 6 5 . 1 ( 3 . 2 ) - 0 . 2 4 8 0 . 8 0 7 *P< .0 5 . **P< .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 154 Question 3 Were the correlations between the chronological age and play age, and between the chronological age and dimension scores, significantly higher within the group of boys without disabilities than within the group of boys with autism? Hypothesis 3 The correlations between the chronological age and play age, and between chronological age and dimension scores, would be significantly higher within the group of boys without disabilities than within the group of boys with autism. The results of the two-sample Fisher’s z test for correlations between the subject’s chronological age and their PPS scores in the two groups were presented in Table 16. In order to identify whether or not the correlation between the subject’s chronological age and their PPS scores in the group of boys without disabilities, is significantly higher than it is in the group of boys with autism— three steps of statistical procedures were performed in this study. First, the correlation coefficient of the chronological age on the PPS play age for each dimension for each of the two samples were computed; and further, Fisher’s z transformation of the sample correlation coefficient was calculated. Finally, Fisher’s z test was performed to statistically compare two sets of correlation coefficients in two samples for the hypothesis test. As a descriptive statistic, the most common method to identify the relationship between two measures is through correlation procedures that are Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 155 concerned with how variations in one variable are associated with variations in another. That is, the correlation coefficients summarize the magnitude and direction of a relationship between two variables (Polit & Hungler, 1995). In this study, to investigate the relationship of chronological age with specific aspects of play performance, correlation analysis was performed. PPS dimension scores and PPS total play age scores were considered as interval-level data. Thus, the Pearson product-moment correlation coefficient was employed. The category scores on PPS were treated as ordinal-level data, since they are scored categorically; therefore, the Kendall tau correlation coefficient was computed for these data. The following labels were offered to interpret the level of correlation: .81- 1.0, almost perfect; .61-.80, substantial; .41-.60, moderate; .21-.40, fair; and .00-.20, slight (Landis & Koch, 1977). As can be seen in Table 16, in the group of subjects with autism, the correlation between chronological age and age scores on the PPS total play age was moderate (r = .42). The correlation between chronological age and age scores on two of the four PPS dimensions was also moderate (i.e., Space Management, r = .54; and Participation, r - .41). The correlation between chronological age and age scores on Material Management (r - .39) and Pretense/Symbolic dimension (r = .22) was only fair. There was, however, a trend of negative and fair (r = .23) correlations between chronological age and age score on Attention category in the group of autistic subjects. In contrast, in the group of subjects without disabilities, the chronological age was almost perfectly correlated Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 156 with age scores on PPS total play age (r = .86) and three of its four dimensions (i.e., Space Management, r - .86; Material Management, r - .87; and Participation, r - .82). The chronological age was substantially correlated with age scores on the Pretense/Symbolic dimension (r = .66). It should be noted that all subjects in the normal group demonstrated the behavior that was categorized as the highest level on the Attention category in PPS. Because all these subjects had the same score on Attention, the correlation coefficient could not be computed. Overall, the results of correlation analysis indicated that, in the group of boys without disabilities, their PPS total play age and its four dimension scores correlated with their chronological age at the substantial level or even higher (i.e. almost perfect), with correlation coefficients ranging from .66 to .87. In the group of boys with autism, their PPS total play age and its four dimension scores correlated with their chronological age at the moderate or fair level, with correlation coefficients ranging from .22 to .54. Moreover, Fisher’s z test was employed to statistically compare two sets of correlation coefficients in two samples for the hypothesis test. As can be seen in Table 16, significant differences were found in these two sets of correlation coefficients between groups. Analysis showed that the correlation between the subject’s chronological age and their age scores on PPS, was significantly lower for PPS total play age and its four dimensions, in the group of boys with autism than in the group of boys without disabilities. Thus, Hypothesis 3 was supported. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 157 Table 16: Com parison o f the Correlation o f Chronological Age w ith Scores on the Preschool Play Scale betw een Boys with Autism and Boys without Disabilities P P S C o m p o n e n t s B o y s w i t h a u t i s m ( N = 3 7 ) B o y s w i t h o u t d i s a b i l i t i e s ( N = 4 2 ) Z P C o r r e l a t i o n z C o r r e l a t i o n z S p a c e m a n a g e m e n t * * 0 0 . 5 4 0 . 6 0 0 0 . 8 6 1 .2 9 2 . 9 3 7 0 .0 0 3 G r o s s m o t o r 0 .5 3 0 . 5 9 $ 0 .7 5 0 . 9 7 1 .6 3 3 0 .1 0 3 I n t e r e s t * <D 0 . 2 6 0 . 2 6 <D 0 .6 5 0 . 7 7 2 . 1 7 0 0 . 0 3 0 M a t e r i a l m a n a g e m e n t * * 0 0 . 3 9 0 .4 1 0 0 . 8 7 1 .3 3 3 . 9 2 6 < 0 .0 0 1 M a n i p u l a t i o n * * <5 0 .2 8 0 . 2 8 0 0 . 7 7 1 .0 2 3 . 1 2 0 0 .0 0 1 C o n s t r u c t i o n <5 0 . 3 8 0 . 4 0 0 0 . 6 7 0 .8 1 1 .7 5 2 0 . 0 8 0 P u r p o s e * 4> 0 .2 0 0 . 2 0 <5 0 . 6 5 0 . 7 7 2 . 4 3 8 0 . 0 1 5 A t t e n t i o n < i> - 0 .2 3 - 0 .2 3 <|> - - - - P r e t e n s e / S y m b o l i c * 0 0 .2 2 0 . 2 2 0 0 . 6 6 0 . 7 9 2 .4 2 5 0 .0 1 5 I m i t a t i o n * 0 .0 3 0 .0 3 4 ) 0 . 5 4 0 . 6 0 2 . 4 4 7 0 . 0 1 4 D r a m a t i z a t i o n $ 0 .1 5 0 .1 5 0 0 . 5 2 0 . 5 7 1 .8 1 2 0 . 0 7 0 P a r t i c i p a t i o n * * 0 0 .4 1 0 .4 3 0 0 . 8 2 1 .1 5 3 .0 7 3 0 . 0 0 2 T y p e ** 4> 0 .1 1 0 .1 1 4) 0 . 6 4 0 . 7 5 2 . 7 6 2 0 .0 0 5 C o o p e r a t i o n * 0 .3 1 0 . 3 2 0 . 6 6 0 . 7 9 2 . 0 1 2 0 . 0 4 4 H u m o r * * < t > 0 . 0 8 0 . 0 8 <5 0 .6 1 0 . 7 0 2 .6 8 1 0 . 0 0 7 L a n g u a g e 4> 0 ,3 1 0 . 3 2 0 0 . 6 2 0 . 7 2 1 .7 2 2 0 . 0 8 5 P P S ( T o t a l P l a y A g e ) * * 0 0 . 4 2 0 . 4 4 0 0 . 8 6 1 .2 9 3 . 6 0 2 < 0 . 0 0 1 Note. z = F i s h e r ’s Z T r a n s f o r m a t i o n Z = Z - s t a t i s t i c = K e n d a l l t a u c o r r e l a t i o n c o e f f i c i e n t s 0 = P e a r s o n c o r r e l a t i o n c o e f f i c i e n t s *P< .0 5 . * * P < .0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 158 Question 4 Did the total score from the PPS, as well as scores for each of the four dimensions, correctly classify or differentiate subjects into their actual groups? Hypothesis 4 Age level scores on the PPS, and its four dimensions, would correctly predict group membership of the subjects. To test Hypothesis 4-that age level scores on the PPS, and its four dimensions, would correctly predict group membership of the subjects-the discriminant analysis was computed. A discriminant function is similar to a regression equation. Just as the regression equation predicts a point along some continuum of criterion measurement, the discriminant function also predicts some point (Polit & Hungler, 1995). However, the analysis provides a critical value along this continuum, which determines the group into which an individual is assigned. In this analysis, each subject was statistically classified into the group to which he was most similar. In addition, the probabilities that he was in that group and in the other group, was given the sum of these probabilities equal to 1.00. Therefore, one not only knew the predicted group for each subject, but also the probability he would be in the other group. The classification rates from discriminant analysis were provided in the Tables 17, 18 and 19. Using the results from discriminant function analysis, a total of 68 of 79 subjects (i.e., 86%) were correctly identified as their actual membership on the basis Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 159 of their score on PPS total play age (p < 0.01, Wilks’ lambda = .409). These were 91% o f the normal subjects and 81% of the autistic subjects. T a b l e 1 7 : D i s c r i m i n a n t A n a l y s i s C l a s s i f i c a t i o n R e s u l t s f o r P r e s c h o o l P l a y S c a l e b y D i m e n s i o n a n d T o t a l P l a y A g e A c t u a l G r o u p M e m b e r s h i p P r e d i c t e d G r o u p M e m b e r s h i p W i l k s ’ L a m b d a P N o r m a l B o y s A u t i s t i c B o y s S p a c e m a n a g e m e n t N o r m a l B o y s A u t i s t i c B o y s 4 1 ( 9 7 . 6 % ) 1 ( 2 .7 % ) 1 ( 2 .4 % ) 3 6 ( 9 7 . 3 % ) 0 . 6 9 5 < 0 .0 0 1 M a t e r i a l m a n a g e m e n t N o r m a l B o y s A u t i s t i c B o y s 2 8 ( 6 6 . 7 % ) 1 2 ( 3 2 . 4 % ) 1 4 ( 3 3 . 3 % ) 2 5 ( 6 7 . 6 % ) 0 . 5 0 9 < 0 .0 0 1 P r e t e n s e / S y m b o l i c N o r m a l B o y s A u t i s t i c B o y s 3 7 ( 8 8 . 1 % ) 8 ( 2 1 . 6 % ) 5 ( 1 1 . 9 % ) 2 9 ( 7 8 . 4 % ) 0 . 3 4 8 < 0 . 0 0 1 P a r t i c i p a t i o n N o r m a l B o y s A u t i s t i c B o y s 3 6 ( 8 5 . 7 % ) 3 ( 8 . 1 % ) 6 ( 1 4 . 3 % ) 3 4 ( 9 1 . 9 % ) 0 . 3 5 2 < 0 . 0 0 1 P P S ( T o t a l P l a y A g e ) N o r m a l B o y s A u t i s t i c B o y s 3 8 ( 9 0 . 5 % ) 7 ( 1 8 . 9 % ) 4 ( 9 . 5 % ) 3 0 ( 8 1 . 1 % ) 0 . 4 0 9 < 0 .0 0 1 Note. N o r m a l b o y s {N=A2). A u t i s t i c b o y s {N= 3 7 ) . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1 6 0 T a b l e 1 8 : D i s c r i m i n a n t A n a l y s i s C l a s s i f i c a t i o n R e s u l t s f o r P r e s c h o o l P l a y S c a l e b y C a t e g o r y A c t u a l G r o u p M e m b e r s h i p P r e d i c t e d G r o u p M e m b e r s h i p W i l k s ’ L a m b d a P N o r m a l B o y s A u t i s t i c B o y s G r o s s m o t o r N o r m a l B o y s A u t i s t i c B o y s 2 8 ( 6 6 . 7 % ) 1 6 ( 4 3 . 2 % ) 1 4 ( 3 3 . 3 % ) 2 1 ( 5 6 . 8 % ) 0 . 9 4 8 0 .0 4 3 I n t e r e s t N o r m a l B o y s A u t i s t i c B o y s 4 1 ( 9 7 . 6 % ) 1 0 ( 2 7 . 0 % ) 1 ( 2 .4 % ) 2 7 ( 7 3 . 0 % ) 0 . 5 4 9 < 0 .0 0 1 M a n i p u l a t i o n N o r m a l B o y s A u t i s t i c B o y s 2 8 ( 6 6 . 7 % ) 7 ( 1 8 . 9 % ) 1 4 ( 3 3 . 3 % ) 3 0 ( 8 1 . 1 % ) 0 . 6 8 8 < 0 .0 0 1 C o n s t r u c t i o n N o r m a l B o y s A u t i s t i c B o y s 3 7 ( 8 8 . 1 % ) 1 0 ( 2 7 . 0 % ) 5 ( 1 1 . 9 % ) 2 7 ( 7 3 . 0 % ) 0 . 4 6 7 < 0 .0 0 1 P u r p o s e N o r m a l B o y s A u t i s t i c B o y s 3 7 ( 8 8 . 1 % ) 9 ( 2 4 . 3 % ) 5 ( 1 1 . 9 % ) 2 8 ( 7 5 . 7 % ) 0 . 5 6 4 < 0 .0 0 1 A t t e n t i o n N o r m a l B o y s A u t i s t i c B o y s 4 2 ( 1 0 0 . 0 % ) 3 4 ( 9 1 . 9 % ) 3 ( 8 . 1 % ) 0 . 9 5 5 0 . 0 6 2 I m i t a t i o n N o r m a l B o y s A u t i s t i c B o y s 3 5 ( 8 3 . 3 % ) 4 ( 1 0 . 8 % ) 7 ( 1 6 . 7 % ) 3 3 ( 8 9 . 2 % ) 0 . 3 6 5 < 0 . 0 0 1 D r a m a t i z a t i o n N o r m a l B o y s A u t i s t i c B o y s 3 8 ( 9 0 . 5 % ) 4 ( 1 0 . 8 % ) 4 ( 9 . 5 % ) 3 3 ( 8 9 . 2 % ) 0 . 3 3 7 < 0 . 0 0 1 T y p e N o r m a l B o y s A u t i s t i c B o y s 3 7 ( 8 8 . 1 % ) 3 ( 8 . 1 % ) 5 ( 1 1 . 9 % ) 3 4 ( 9 1 . 9 % ) 0 . 3 5 3 < 0 . 0 0 1 C o o p e r a t i o n N o r m a l B o y s A u t i s t i c B o y s 3 5 ( 8 3 . 3 % ) 3 ( 8 . 1 % ) 7 ( 1 6 . 7 % ) 3 4 ( 9 1 . 9 % ) 0 . 4 5 4 < 0 . 0 0 1 H u m o r N o r m a l B o y s A u t i s t i c B o y s 3 1 ( 7 3 . 8 % ) 1 1 ( 2 6 . 2 % ) 3 7 ( 1 0 0 . 0 % ) 0 . 3 1 4 < 0 . 0 0 1 L a n g u a g e N o r m a l B o y s A u t i s t i c B o y s 3 3 ( 7 8 . 6 % ) 7 ( 1 8 . 9 % ) 9 ( 2 1 . 4 % ) 3 0 ( 8 1 . 1 % ) 0 . 4 9 9 < 0 . 0 0 1 Note. N o r m a l b o y s (N- 4 2 ) . A u t i s t i c b o y s (1V= 3 7 ) . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 161 T a b l e 1 9 : C l a s s i f i c a t i o n R a t e s f r o m D i s c r i m i n a n t A n a l y s i s , f o r P r e s c h o o l P l a y S c a l e b y D i m e n s i o n a n d C a t e g o r y P P S C o m p o n e n t s P r e d i c t e d G r o u p M e m b e r s h i p O v e r a l l s u b j e c t s ( N = 7 9 ) N o r m a l G r o u p ( N = 4 2 ) A u t i s t i c G r o u p ( N = 3 7 ) N o r m a l t o N o r m a l s & A u t i s t i c t o A u t i s t i c s N o r m a l t o N o r m a l s A u t i s t i c t o A u t i s t i c s S p a c e M a n a g e m e n t 7 7 ( 9 7 . 5 % ) 4 1 ( 9 7 . 6 % ) 3 6 ( 9 7 . 3 % ) G r o s s m o t o r 4 9 ( 6 2 . 0 % ) 2 8 ( 6 6 . 7 % ) 2 1 ( 5 6 . 8 % ) I n t e r e s t 6 8 ( 8 6 . 1 % ) 4 1 ( 9 7 . 6 % ) 2 7 ( 7 3 . 0 % ) M a t e r i a l M a n a g e m e n t 5 3 ( 6 7 . 1 % ) 2 8 ( 6 6 . 7 % ) 2 5 ( 6 7 . 6 % ) M a n i p u l a t i o n 5 8 ( 7 3 . 4 % ) 2 8 ( 6 6 . 7 % ) 3 0 ( 8 1 . 1 % ) C o n s t r u c t i o n 6 4 ( 8 1 . 0 % ) 3 7 ( 8 8 . 1 % ) 2 7 ( 7 3 . 0 % ) P u r p o s e 6 5 ( 8 2 . 3 % ) 3 7 ( 8 8 . 1 % ) 2 8 ( 7 5 . 7 % ) A t t e n t i o n 4 5 ( 5 7 . 0 % ) 4 2 ( 1 0 0 . 0 % ) 3 ( 8 . 1 % ) P r e t e n s e / S y m b o l i c 6 6 ( 8 3 . 5 % ) 3 7 ( 8 8 . 1 % ) 2 9 ( 7 8 . 4 % ) I m i t a t i o n 6 8 ( 8 6 . 1 % ) 3 5 ( 8 3 . 3 % ) 3 3 ( 8 9 . 2 % ) D r a m a t i z a t i o n 7 1 ( 8 9 . 9 % ) 3 8 ( 9 0 . 5 % ) 3 3 ( 8 9 . 2 % ) P a r t i c i p a t i o n 7 0 ( 8 8 . 6 % ) 3 6 ( 8 5 . 7 % ) 3 4 ( 9 1 . 9 % ) T y p e 7 1 ( 8 9 . 9 % ) 3 7 ( 8 8 . 1 % ) 3 4 ( 9 1 . 9 % ) C o o p e r a t i o n 6 9 ( 8 7 . 3 % ) 3 5 ( 8 3 . 3 % ) 3 4 ( 9 1 . 9 % ) H u m o r 6 8 ( 8 6 . 1 % ) 3 1 ( 7 3 . 8 % ) 3 7 ( 1 0 0 . 0 % ) L a n g u a g e 6 3 ( 7 9 . 7 % ) 3 3 ( 7 8 . 6 % ) 3 0 ( 8 1 . 1 % ) P P S ( T o t a l P l a y A g e ) 6 8 ( 8 6 . 1 % ) 3 8 ( 9 0 . 5 % ) 3 0 ( 8 1 . 1 % ) Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 162 Of the four play dimensions, Space Management was the best single predictor of group membership of the boys, which correctly classified 98% of the subjects (p < 0.01, Wilks’ lambda = .695). The score from the Participation dimension correctly classified 89% of the subjects (p < 0.01, W ilks’ lambda = .352). The score from Pretense/Symbolic dimension correctly classified 84% of the subjects (p < 0.01, W ilks’ lambda = .348). The score from the Material Management dimension correctly classified 67% of the subjects {p < 0.01, W ilks’ lambda = .509). This measure was only considered as a fair predictor of group membership because its classification rate was only slightly greater than chance (chance alone would have correctly classified 50% of the subjects). Interestingly, using the results from discriminant function analysis, a total of 34 of 37 subjects with autism (i.e., 92%) were misclassified as normal boys on the basis of their category score of Attention; and a total of 16 of 37 subjects with autism (i.e., 43%) were misclassified as normal boys on the basis of their category score of Gross Motor. The results of such high misclassification rate on Gross Motor or Attention categories might indicate that boys with autism do not necessarily have marked deficits in particular aspects of Gross Motor or Attention capacity, as measured in the PPS. In sum, in order to determine how well the scores from the PPS correctly predicted the actual group membership of individual subjects, the discriminant analyses were performed. Hypothesis 4, that scores from the PPS total play age and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 163 from its four dimensions, would overall correctly classify subjects into their actual groups, was accepted. The discriminant function analyses in this study indicated that the PPS could be used to differentiate autistic subjects from normal children with a high degree of precision/classification rates. Also, the findings in these analyses might provide the evidence to support that the play performance of boys with autism, as measured by PPS, differed significantly from that of the compared group of boys without disabilities. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 164 CHAPTER Y DISCUSSION A detailed description of research results and findings, in quantitative terms and in statistics table form, was provided in the previous chapter. In this chapter, possible explanations for the major findings on the play performance in two groups of children will be discussed. The application of PPS in the Taiwanese population will then be addressed. The study limitations will also be identified, followed by the suggestions for future studies. PPS is an observational assessment designed to give a “developmental description of typical play behavior through ages 0 to 6 years” (Knox, 1997, p. 37). Behavioral items are listed under each category. They were determined through a synthesis of existing developmental and play scales, and they were written as actions that the child performs (Knox, 1997). In this study, to score the subject’s performance in using the PPS, the researcher underlined each behavioral item on the scale when the behavior was observed. These underlined behavioral items were reviewed and were used to make the following description of subjects’ behaviors. Additionally, at the time of the observation, the researcher made memos and notes, including such information as the children’s involvement and engagement, number of peers present, preferred type of play, toys present, equipment involved, setting, emotions expressed, verbalizations, external influences, and any unusual behavior that interested the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 165 researcher. When necessary, the information in the field-notes was used to interpret the data. Performance o f Taiwanese Subjects with Autism This study was designed to examine and compare the play performance of boys with autism and boys without disabilities in Taiwan. In this study, it was clear from the data that there were significant differences in the mean scores of the two groups in the majority of the areas measured by the Preschool Play Scale (PPS). Indeed, when compared to the normally developing control subjects, the Taiwanese subjects with autism demonstrated poor performance across the board on the PPS (i.e., Space Management, Material Management, Pretense/Symbolic, Participation) and they obtained significantly lower scores on PPS total play age and its four play dimensions (Table 8). Participation The participation dimension measured the individual’s level of social interaction with peers in the free-play episode. The significant difference in the mean score between the two groups on this dimension indicated that the Taiwanese boys with autism had difficulty in exhibiting the age-appropriate amount/manner of social interaction in their play, as compared with the normal subjects. The decreased level of participation in the boys with autism might have resulted from (a) their marked impairment in making peer relationships and their absence of focus to interact with others (Gillberg et al., 1990; Lord, 1984; McHale, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 166 1983); (b) their inability to get along with others (e.g., by a lack of turn-taking, sharing, negotiation, or compromise) (Baron-Cohen, 1995); (c) their difficulty in perceiving the abstract concept of “incongruity” which limited their understanding and expression of humorous words or events (Baron-Cohen, 1995); and (d) their marked impairment in communicating with others (e.g., deficits in the use of verbal and nonverbal communication, mutual intersubjectivity, social reciprocity, language comprehension, stereotyped or unusual features in the use of communicative language) (Baron-Cohen, 1995; Lord, 1985; Schopler & Mesibov, 1985). Autistic children were more likely to display isolated social behavior (Gillberg et al., 1990), to exhibit solitary play (McHale, 1983), and to have difficulty in responses to interaction during play (Lord, 1984). As the results showed, 27% of subjects with autism (10 out of 37) demonstrated no effort to interact with others (neither adults nor peers) regardless of whether the other people were familiar or complete strangers (i.e., rated as 6-month). These subjects spent extended periods of time staring blankly into space or wandering aimlessly. Many of them held something in their hands: a piece of paper, toy car, toy lid, or a small block, for instance. Also, even if many of them occasionally engaged in some sort of play with toys or objects, they kept their distance from others or brought the toys somewhere else to play, if space was available. If space was limited, or if sometimes they were not allowed to go wherever they wanted, commonly they would turn their backs to those who were invading their play space. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 167 Results showed that 41% of autistic subjects (15 out of 37) showed combination patterns of solitary and onlooker behaviors in their play (i.e., rated as 18-month). That is, these children would walk around to observe what others were doing when they were not engaged in focused solitary play. Some subjects with autism were able to engage in parallel play by playing in the company of others with similar toys, but their play still remained independent without any attempt to associate with companions (i.e., rated as 30-month). Only a few individuals (three subjects) were noted to display associative play involving some peer interaction (i.e., rated as 48-month). They were also capable of understanding certain simple rules in the play in which they participated. Two patterns were observed in the subjects with autism regarding the children’s ability to cooperate while participating with others in play. Five subjects with autism demonstrated strongly seeking attention to self and were preoccupied with self-stimulatory behaviors (i.e., rated as 18-month). As observed, when these subjects were approached by someone who asked for or took away their toys, they would stare blankly into space, walk away or turn away, or simply look for another substitute. They showed no reactions upon the approach, as if nothing had happened, and then they moved on. Nineteen percent of the autistic subjects (19 out of 37) demonstrated the opposite pattern. That is, they were observed to be very possessive and persistent, and very disruptive (i.e., rated as 30-month). They strongly resisted their toys being Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 168 taken away. Oftentimes they would simply grab an object without asking or requesting it in any way. Moreover, the children demonstrated less sharing and more snatching and hoarding, as well as bossy and controlling behavior. Also, the low score in the dimension of Participation in autistic subjects might be attributed to their difficulties in understanding and expressing humorous or incongruous words/events and their difficulties in communicating appropriately with others in play. Performance in both the area of their sociability and the area of their communication with others seems to be consistent among the autistic subjects with some behaviors that the individuals with a “theory of mind” deficit would perform. The “theory of mind” is defined as (a) the ability to infer one’s own and other people’s mental states, such as thoughts, beliefs, desires, intentions, pretense, and perception, and (b) the ability to link, to make sense, to interpret, and to predict people’s actions and behaviors (Baron-Cohen, 1995). A “theory of mind” deficit would make it difficult for an individual to understand a concept of “incongruity” and to either be humorous or understand the humor in it. Consequently, in this study, 54% of autistic subjects (20 out of 37) were rated at the twelve-month age level, indicating that they responded to humorous situations initiated by adults. They laughed at unexpected and exaggerated actions, and expressed observable joy in physical games or movement play such as tickling games, tag, or a chasing play. Some of these subjects laughed at exaggerated movements or voices (e.g., funny animal characters who produced funny voices and Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 169 performed unusual and/or foolish actions on television). Only 3 out of the 37 subjects scored into the thirty-month level and were observed laughing at simple combinations of incongruous events and incongruous word usages. No other characteristics of humor such as those associated with nonsense words (i.e., rated as 48-month), distortions of the familiar (i.e., rated as 60-month), or wordplay on multiple meanings (i.e., rated as 72-month) were observed among subjects with autism in this study. Deficits in spontaneous verbal and nonverbal communication are the distinguishing characteristic of children with autism (Lord, 1985; Scholper & Mesibov, 1985). It is believed that the problems in communication among children with autism can be attributed to the deficits in the establishment of joint attention with others (defined as directing another’s attention for the purpose of sharing the focus on an entity or event) and have led to a lower likelihood of the use of pointing, eye contact, or any indicative gestures to request out-of-reach objects, to request help, or to comment and share on things/events in autistic children (Lord, 1985; Schopler & Mesibov, 1985). In this study, 43% of autistic subjects (16 out of 37) were rated at the twelve-month level, indicating that simple gestures and some responses toward familiar words/questions were observed in play. Only five subjects were observed using descriptive vocabulary (i.e., rated as 48-month), and two subjects were rated at the sixty-month level because long narratives and questions were consistently observed in play. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 170 In summary, the more mature behaviors of sociability (e.g., associative play, cooperative play, competitive play, play with rules, turn-taking, compromising, negotiating, being humorous toward complex combinations of incongruous events/words and wordplay, and the use of appropriate manners to communicate with others at play) were rarely observed among subjects with autism in this study. Therefore, it is not surprising that the subjects with autism scored significantly lower on the dimension of Participation than did the subjects without disabilities. Pretense/Symbolic The Pretense/Symbolic dimension measures the individual’s imitative and imaginative capacity and the amount/manner of dramatic play exhibited (Knox, 1997). The result in this study provided additional support to the common belief that children with autism have impairments in symbolic functioning at play (DeMyer et al., 1967; DeMyer et al., 1972; Gillberg et al., 1990; Mundy et al., 1994; Mundy et al., 1987; Osterling & Dawson, 1994; Prior, 1974; Sigman et al., 1986; Sigman & Ungerer, 1984; Smith & Bryson, 1994; Stone et al., 1990; Weiner et al., 1969; Wing & Gould, 1979). The poor performance on the dimension of Pretense/Symbolic in subjects with autism might be linked to (a) their difficulty in reproducing the actions/events/schemas of the cultural environment through imitation, and (b) their inability to understand the representational use of abstract symbols as well as their impaired comprehension of the mental state of pretending or imagining. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 171 In the reviewed literature, autistic children performed more poorly on both the imitation of body movements and the imitation of actions with objects, as compared to children with mental retardation and children with typical development (Prior, 1974; DeMyer, Alpem, Barton, DeMyer, Churchill, Hingtgen, Bryson, Pontinus, & Kimberlin, 1972; Sigman & Ungerer, 1984; Smith & Bryson, 1994; Stone et al., 1990). However, it was believed that autistic individuals had certain basic capacities to imitate familiar actions (Dawson & Adams, 1984), both gestures and unfamiliar actions with objects (Charman & Baron-Cohen, 1994), facial gestures (Loveland, Tunali-Kotoski, Pearson, Brelsford, Ortegon, & Chen, 1994), and a series of pretend acts (Libby, Powell, Messer, & Jordan, 1997). Drawing from the data in this study, 41% of subjects with autism (15 out of 37) had at least some basic imitation skills typical of twelve-month old children. That is, they were able to imitate some particular familiar body gestures and actions demonstrated by parents or familiar adults. Also, eight subjects with autism showed their capability to imitate simple, unfamiliar, or novel movements and actions with objects (i.e., rated as 18-month). One-third of the autistic subjects achieved a certain level of imitation skill that children in their second year have, being able to exhibit a simple representational imitation with objects, for example, pushing toy cars along the edge of a table and then passing it underneath a block-built bridge. One possible explanation for the poor imitation skills with objects in autistic children would be the difficulty they have in developing a more advanced knowledge Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 172 of object use (Mundy et al, 1987; Demyer et al, 1967; Sigman & Ungerer, 1984; Stone et al, 1990; Weiner, Ottinger, & Tilton, 1969). It was believed that autistic individuals displayed nonfunctional use of objects (Mundy et al, 1987; Sigman & Ungerer, 1984; Stone et al, 1990). For example, in this study, one autistic subject spent an extended period of time playing with a toy phone set by picking up the handset and putting it back to the position repetitively without showing any attempt to make dialing action or to bring the handset to his ear. Another autistic subject carried a toy knife while walking around, waved it, and poked at the rubbish and the hole on the container. When the mother gave him a toy apple (two half parts sticking together with Velcro) to cut in two, he failed to do so. Thus, these examples revealed the lack of the knowledge of objects being used in a symbolic manner among autistic children. As can be seen from the data, nine subjects with autism produced some abstract representational acts of object use, and only four out of these nine subjects demonstrated some symbolic imitation from real world experience on objects used to create a dramatic theme (i.e., rated as 48-month). For example, one subject asserted that he was a police car, wore a red bucket as its siren, and made a wailing sound. One subject glued cotton balls on a sheet of paper and told the teacher there were clouds in the sky (i.e., use of objects to represent another different objects). One subject pretended to fry vegetables, holding a cooking ladle in one hand and held a cooking pan in the other hand, with all objects being imaginary (i.e., acts implying Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 173 the existence of imaginary objects). Approximately, 57% of autistic subjects (21 out of 37) showed no evidence at performing dramatic play in any way. As noted, only a few subjects with autism were capable of displaying symbolic acts in play such as making one object represent another, different object, producing acts implying toys as agents of actions, or imagining absent imaginary objects to be present. Thus, the imagination, pretend actions, and the symbolic representation of objects were rarely observed at play in subjects with autism. This finding indicated that it was difficult for the subjects with autism in this study to understand and separate reality from make-believe as the dimension of Pretense/Symbolic measures. Again, the behaviors of subjects with autism seems to be consistent with what an individual would do due to his/her lack of “a theory of mind”, that impairs his/her understanding of the mental state of “pretending” or “imagining” and the concept of “incongruity” (Baron-Cohen, 1995). Apparently, the difficulty in producing pretend play and distortion of the reality would be anticipated in children with autism, which make the low score on the dimension of Pretense/Symbolic among subjects with autism understandable. Material Management The Material Management dimension measures the individual’s performance in material manipulation, constructional capability, goal-directed activity, and their attention span during independent play. The explanations of the low score in autistic subjects in this dimension might be (a) their restricted knowledge of object use Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 174 (Mundy et a l, 1987; DeMyer et al., 1967; Sigman & Ungerer, 1984; Stone et al., 1990; Weiner, Ottinger, & Tilton, 1969); and/or (b) their stereotyped patterns of behaviors, focus, and activities (APA, 1994; DeMyer et al., 1967; Lord et al, 1994; Mundy et al., 1987; Ohta et al., 1987; Sigman & Ungerer, 1984; Stone et al., 1990; Volkmar et al., 1986; Volkmar et al., 1994; Weiner et al. 1969; Wing, 1969; WHO, 1993). It is common for autistic populations to exhibit nonfunctional use of objects (Mundy et al., 1987; Sigman & Ungerer, 1984; Stone et al., 1990). In the domain of Material Management, the fine motor activities, control, and accomplishment are considered (Knox, 1997). Taiwanese subjects with autism were rated with a low score on this dimension because they were observed to manipulate objects in non constructive and non-function-oriented ways. For example, approximately one-third of the subjects with autism in this study demonstrated non-constructive ways of object manipulation (e.g., licking, mouthing, carrying, spinning, banging, and shaking any objects they grabbed) and some self-directed movements such as finger flicking and arm flapping were frequently showed. Many children with autism were observed to pat or feel objects with particular textures, to squeeze, poke, or dispersed flutter to send, and to splash the pooling water over the ground. Several subjects with autism were observed poking their fingers into holes, raking small objects out from small holes, pinching small objects, and putting them into their mouths. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 175 Subjects with autism in this study were rarely observed showing appropriate use o f instruments in fine motor activities when their normally developing peers were demonstrating good manipulation of objects in scribbling, cutting with scissors, pasting, tracing, drawing, coloring, writing, and making detailed constructions that the higher scores were rated. Conversely, many subjects with autism managed their material surroundings in the ways that were rated low scores on PPS. For example, in this study, the motor behaviors that caused a desired effect to occur were observed in one-third of the subjects with autism. These children appeared to understand the connection between the moves they made and the contingent effects which would be rated at the twelve-month age level on PPS. Several subjects dropped the particular items on the table or floor, and grabbed the items to knock on others objects to create the different sounds. Some subjects stuck with the pop-up/out toys that activated by pressing a button or triggering a switch. There was one child who frequently lay on the floor in public to listen to water drops coming out from the drainage ditch and drainpipe. One child enjoyed flushing the toilet in order to produce running water. One child continuously poured beans into a glass container. Two children liked to drop coins into a container for the sounds it created. Three children operated a stereo by repetitively turning the volume up and down. However, some children with autism exhibited the capability of combining action patterns. These autistic subjects could drop beans into containers (rated as 12- Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 176 month), begin to combine items in typical relational patterns (rated as 18-month), string beads (rated as 24-month), dump items out of the container and put together a few puzzle pieces (rated as 30-month), and/or dismantle/rebuild objects and sort/match materials in a few limited ways (rated as 36-month). However, some behavioral descriptors that were frequently observed in normal controls, such as three-dimensional design (rated as 48-month), the construction of complex structures (rated as 60-month), and the making of recognizable products (rated as 72-month), were rarely observed in autistic subjects. The poor performance on dimension of Material Management in subjects with autism might be attributed to their stereotyped patterns of focus. Persistent preoccupation with the specific part of objects that can be spun, twirled, flicked, tapped, or whirled were commonly found in autistic populations (DeMyer et al., 1967; Weiner, Ottinger, & Tilton, 1969; Ohta et al., 1987). Subjects with autism in this study had tremendous interest in specific stimulating properties of certain shapes and materials. For example, several subjects responded only to such materials of round/circle shapes like coins, gongs, adult’s eyeglass, lens of a camera, lids of teapots, buttons on clothes, round-shaped cookies, people who had round-shaped faces or had round-shaped eyeglasses on, saucer toys, and so on. Several subjects in this study were highly attracted to materials with elastic properties: rubber bands, leather belts, long bands or ribbons attached to clothes, for instance. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 177 The flexibility of these materials enabled these children to spend extended periods of time creating numerous shapes in novel ways; to twirl a piece of string and become transfixed by its movement, for example. Moreover, some forms of sensory stimulation associated with lighting changes were apparently notable among individuals with autism in this study. Accordingly, several subjects occupied themselves with watching their hands move, partially blocking their eyesight with objects for the production of desired lighting-stimulation, watching flickering lights, switching the lights on and off, or flashing lights. Interestingly, several subjects were observed to persist into the horizontal and vertical lining characteristic of objects. They kept their concentration tightly focused on arranging or lining up objects (e.g., blocks, spoons, chopsticks, pens, shoes, dolls, cups). In sum, the restricted knowledge of object use and the stereotyped patterns of focus among autistic populations might restrain them from managing their material surroundings in more mature ways. As normal children generally focused on the detailed and specific design of multiple, complex, and realistic construction products with interlocking pieces and with the functional use of tools in a more mature level of material management, the subjects with autism in this study remained in a lower developmental level with respect to object manipulation and construction, matching and sorting objects with regards to their restricted thinking, or simply in manipulating objects tied to some forms of sensory exploration or stimulation. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 178 Under the dimension of Material Management, there was one interesting finding in this study that this researcher would like to address: Taiwanese autistic subjects were rated as having an unanticipated high score in the category of Attention, and no statistical difference was found between the children with autism and normal children on the this category score. Only three subjects with autism in this study did not get the highest score (i.e., 72-month) in this category. However, this researcher believes that although there was no statistical evidence indicating the children with autism had worse attention spans than those without autism on the observational instrument used in this study, it does not mean that they appropriately performed functions of attention in the usual manner. In the literature reviewed, impairments in attention among the autistic population were proposed by several researchers, from the perspective of neurodevelopmental mechanisms of autism. These researchers believed that the abilities of basic information-processing and attentional operations in persons with autism were impaired to some degree (Wainwright-Sharp & Bryson, 1993, 1996). The research suggested that these problems would certainly affect numerous areas of children’s daily functioning (Wainwright-Sharp & Bryson, 1993, 1996). Indeed, Taiwanese subjects with autism in this study frequently displayed problems in attention, as observed by this researcher in the period that the PPVT-R test was administered, and also in the observed sections of free play. In particular, they exhibited atypical features and behaviors that were potentially associated with Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 179 attention, such as inattention, poor concentration, and problems in appropriately choosing, attending to, and processing the most essential cues from the stimulus-rich environments in which they were observed. Specifically speaking, during the observation periods, the subjects with autism demonstrated limited consideration of incoming information, a unique problem associated with attention. Approximately two-thirds of the subjects with autism were found to have a tendency to eliminate all but a few cues available to them in the surrounding environment. This researcher believed that such behavior was related to their difficulty in discriminating multiple stimuli: selecting, focusing, and responding appropriately to promoting cues, which was defined as “stimulus over-selectivity” in the literature (Koegel & Koegel, 1995; Lovaas, Koegel, & Schreibman, 1979). In this study, as a result of stimulus over-selectivity, subjects with autism were frequently observed to engage in one stereotyped pursuit, which completely absorbed them for the entire observation section. Also, it was not uncommon for children with autism to attend to or focus on specified activities that contained certain stimulus properties (e.g., color, shape, texture) for lengthy periods through their characteristic of stimulus overselectivity. For example, three subjects spent a certain period of time watching the turning blades of a ceiling fan, similarly to four subjects who turned wheels of the model cars, two subjects who played with sand, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 180 one subject who squeezed rubber bands, and one subject who kept walking himself in a circle, within the playground where many other peers play around. Many subjects with autism in this study exhibited their persevering behaviors of engagement on specified activities for a prolonged time without being distracted by any events going on around them. These observations demonstrated that these subjects with autism were particularly capable of sustaining attention and remaining focused on activities over extended periods of time. Additionally, in this researcher’s observation, this acceptable level of concentration was typically only applied for self-generated activities and not for the activities imposed by others. Obviously, subjects with autism in this study certainly showed the capability of maintaining their attention on what they were interested in. Since the PPS measures children’s attention with the only consideration of the length of time spent in independent play, it was not surprising that the high scores were rated in subjects with autism on their Attention performance. Therefore, it was understandable that there was no difference between autistic group and normal group on attention score in PPS. There is a pressing need to further examine the potential impairment in more specific aspects of attentional functioning and its related effects in the daily lives among the Taiwanese population with autism, other than the ones measured in PPS. The significance of future work in this area will be largely dependent on successfully addressing all components of attentional functioning in population with autism. To Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 181 achieve this goal in the future, Burack and Erins’ (1997) concept of attention, is strongly recommended by this researcher to be used in the future investigations regarding the potential areas of attentional deficiencies among persons with autism. Burack and Enns (1997) proposed a model of attention which is comprised of several components of widely different attentional functions: (a) arousal baseline that determines the levels of stimulus intensity needed to elicit attentional processes), (b) sustained attention (the focused/divided distribution of attention over space and time), (c) orienting (adapting to particular visual field locations), (d) gazing (focusing attention to a spatial area), (e) filtering (selecting objects based on specific attributes), (f) searching (for targets), and (g) expecting information (of a certain kind or in a predesignated location). Again, the category of attention in PPS assesses the length of time in which children play with single objects or themes. This exactly corresponds to Burack and Enns’ (1997) definition of “sustained attention”. Therefore, this researcher believes that the attentional problems in daily living among the subjects in autism, might not be evidenced and manifested in the performance on the standardized instrument of Knox’s PPS since it only measures children’s sustained attention, a specific aspect/component of attention, which might be independent of other potentially confounding areas of attentional functioning. Additional aspects of attention should be included in future revision of the PPS. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 182 Space Management In the initial analysis presented at Table 8, Taiwanese subjects with autism demonstrated poor performance across the board on PPS, thus, the autistic subjects scored significantly lower than did the normal subjects on PPS total play age and its four dimensions of Space Management, Material Management, Pretense/Symbolic and Participation. The significant differences between autistic boys and normally developing boys in the dimension of Space Management was not expected because the literature indicates that children with autism did not differ from their normal peers in their gross motor functioning. This researcher speculated that the general low level of cognitive functioning among subjects with autism in the present study, might serve as the possible explanation for the poor performances in the Taiwanese population with autism on Space Management, as well as the other play dimensions. The intellectual development of autistic individuals appeared to be closely associated with the adaptive behaviors, skills acquisition, tasks performance, outcome and prognosis of autistic individuals (DeMyer, Barton, DeMyer, Norton, Allen, & Steel, 1973; Letter, 1974, 1978; Rutter, 1970, 1985). Therefore, before any further discussion, it’s necessary to review the performance the subjects with autism had on PPVT-R, a standardized test used in this study to examine the subject’s level of cognitive functioning. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 183 Performance on PPVT-R Apparently, as can be seen at Table 7, 19 out of the 37 subjects with autism (51%) in the present study could not independently complete the Peabody Picture Vocabulary Test-Revised (PPVT-R), a test of intellectual understanding of receptive vocabulary and verbal concepts. Moreover, approximately 16% of the subjects with autism needed certain levels of assistance from the mother, the teacher, or the supervising adult to complete the test. In these subjects, the companionship and assistance o f people whom the autistic subjects trusted were effective in eliciting subject’s optimal cooperation and effort. For example, to help conduct the evaluation successfully, these adults individually provided useful and effective reinforcement for their child. Thus, the subject’s favorite food or even certain stereotyped toys and activities (e.g., spinning wheels of toy cars, playing favorite musical songs, giving pens for the subject to hold in his hand), were often used as reinforcers to motivate and maintain the required level of the subject’s attention and engagement to complete the test. Interestingly, several parents and teachers gave the researcher very useful and specific tips in pacing evaluative test presentations followed by their child’s rhythm, as well as in adjusting the researcher’s tone and volume of voice attuned to their child’s style, that successfully ensured the child’s comfort, interest, attention, and involvement throughout the entire test period. Among those subjects who could not be tested, 7 of them (about 50%) were unable to indicate “yes” and “no” in any Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 184 communicative manner. Neither pointing nor nodding the head was shown, and the others demonstrated their incapability of following instructions and sustaining adequate attention on the test. The subjects’ performances on PPVT-R provided an indication of their intellectual understanding of receptive vocabulary and verbal concepts. It is clear from the data that the mean scores on the test differed significantly between the two groups as presented in Table 7. The mean scores on the PPVT-R were considerably lower in subjects with autism. This suggests that the subjects with autism in this study, when compared with the normally developing subjects of the same age group, demonstrated a considerable degree of impairment in intellectual functioning (i.e., the domain of receptive vocabulary reorganization and comprehension), which may lead to their decreased performance on the overall developmental areas of play as measured by PPS. As noted in the literature, many children diagnosed with autism display some degree of mental retardation. Approximately 75% of individuals with autism were considered as retarded in their daily functioning with IQ score in the range of 35-50 (APA, 1994). About 70% to 80% of autistic individuals were found to be mentally retarded, with the vast majority of them obtaining IQ scores in the moderate to severe ranges of mental retardation (Wing & Gould, 1979). Though the two groups of subjects in this study were generally matched on the basis of their chronological age, the autistic subjects had significantly lower intellectual scores (as measured by Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 185 the Chinese Version of Peabody Picture Vocabulary Test-Revised) than the normally developing controls. Given the consideration that children’s behavior might vary and be associated with their level of cognitive development (i.e., degree of mental retardation), chronological age, and severity of abnormalities; it is particularly crucial to control for the certain level of subject’s intellectual capacity in order to make clear conclusions about children’s play performance specific to autism. Thereby, a secondary analysis of subjects’ play performance was performed when their intellectual capacity was controlled. Secondary Analysis Fifteen subjects with autism, who independently completed the Chinese Version of PPVT-R with the standard score higher than 70, were selected to compare their performance with the 30 normally developing controls. These normal boys were chosen from the participants who had already participated in this study. Every autistic subject was matched with two normal subjects within three months of the autistic subject’s chronological age. Having a PPVT-R score higher than 70 in the subjects with autism might increase confidence that if any differences are found between the children with and without autism, they would be related to autism, and not to mental retardation. The comparison of the performance of these selected subjects on PPS and PPVT-R were provided in Table 20. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 186 Table 20: The Performance o f the Subgroup in Boys with Autism and Boys without Disabilities on PPS and on PPV T-R B o y s w i t h a u t i s m (n— 15) B o y s w ithout d i s a b i l i t i e s ( n = 3 0 ) T P P P S C o m p o n e n t s M e a n ( S D ) M e a n ( S D ) S p a c e m a n a g e m e n t 5 3 . 4 ( 1 1 . 3 ) 5 8 . 2 ( 7 .2 ) 1 .7 3 0 0 .0 9 1 G r o s s m o t o r 6 0 . 8 ( 1 0 . 6 ) 6 0 . 8 ( 8 .9 ) 0.000 1.000 I n t e r e s t * 4 6 . 0 ( 1 5 . 8 ) 5 5 . 6 ( 6 .7 ) 2 . 2 5 2 0 . 0 3 8 M a t e r i a l m a n a g e m e n t * * 4 8 . 9 ( 1 2 . 3 ) 6 1 . 2 ( 6 . 4 ) 3 . 6 3 2 0 . 0 0 2 M a n i p u l a t i o n * 4 8 . 8 ( 1 7 . 3 ) 6 0 . 4 ( 9 . 2 ) 2 . 4 3 7 0 . 0 2 5 C o n s t r u c t i o n * * 3 6 . 4 ( 1 5 . 3 ) 5 6 . 0 ( 9 . 6 ) 4 . 5 3 5 < 0 . 0 0 1 P u r p o s e * 4 1 . 6 ( 2 1 . 3 ) 5 6 . 4 ( 9 .0 ) 2 .5 7 5 0 . 0 2 0 A t t e n t i o n 6 8 . 8 ( 1 2 . 4 ) 7 2 . 0 ( 0 . 0 ) 1 ,0 0 0 0 . 3 3 4 P r e t e n s e / S y m b o l i c * * 2 7 . 6 ( 1 3 . 3 ) 5 3 . 9 ( 1 1 . 4 ) 6 . 8 9 4 < 0 .0 0 1 I m i t a t i o n * * 2 9 . 2 ( 1 3 . 4 ) 5 4 . 0 ( 1 1 . 3 ) 6 . 5 4 0 < 0 . 0 0 1 D r a m a t i z a t i o n * * 2 6 . 0 ( 1 3 . 5 ) 5 3 . 8 ( 1 1 . 6 ) 7 .1 5 5 < 0 . 0 0 1 P a r t i c i p a t i o n * * 3 1 . 0 ( 1 0 . 0 ) 5 4 . 9 ( 1 0 . 9 ) 7 . 1 2 9 < 0 . 0 0 1 T y p e ** 3 3 . 6 ( 1 4 . 3 ) 6 0 . 0 ( 1 0 . 5 ) 7 . 0 4 8 < 0 .0 0 1 C o o p e r a t i o n * * 3 2 . 0 ( 1 4 . 3 ) 5 6 . 4 ( 1 3 . 0 ) 5 . 7 5 7 < 0 .0 0 1 H u m o r * * 2 0 . 4 ( 5 . 9 ) 4 8 . 2 ( 1 2 . 5 ) 1 0 .1 4 9 < 0 . 0 0 1 L a n g u a g e * * 3 8 . 0 ( 1 4 . 3 ) 5 4 . 8 ( 1 1 . 7 ) 4 . 2 2 6 < 0 . 0 0 1 P P S ( P l a y a g e ) ** 4 0 . 2 ( 1 0 . 6 ) 5 7 . 0 ( 8 . 2 ) 5 .8 9 1 < 0 .0 0 1 Note. B o y s w i t h a u t i s m a r e t h e s e w h o h a s PPV T-R s t a n d a r d s c o r e h i g h e r t h a n 7 0 ( n = 1 5 ) . B o y s w i t h o u t d i s a b i l i t i e s a r e c h o s e n b y t h e r u l e t h a t e v e r y a u t i s t i c s u b j e c t is m a t c h e d w i t h t w o n o r m a l s u b j e c t s w i t h i n t h r e e m o n t h s o f a u t i s t i c s u b j e c t ’s c h r o n o l o g i c a l a g e (n=30). *P < .0 5 . * * P < . 0 1 . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 187 Table 20 (continued) P P V T - R A d m i n i s t r a t i o n B o y s w i t h a u t i s m ( n = 1 5 ) B o y s w i t h o u t d i s a b i l i t i e s ( n = 3 0 ) T P P P V T - R s t a n d a r d s c o r e P P V T - R s t a n d a r d s c o r e n M e a n ( S D ) n M e a n ( S D ) C h r o n o l o g i c a l a g e g r o u p 3 6 - 4 1 m o n t h s 0 ( 0 / 4 ) - 0 ( 0 / 6 ) - - - 4 2 - 4 7 m o n t h s * 4 ( 4 / 6 ) 1 0 2 . 5 ( 2 1 .2 ) 7 ( 7 / 7 ) 1 2 7 . 0 ( 1 0 .6 ) 2 .6 1 1 0 .0 2 8 4 8 - 5 3 m o n t h s * * 3 ( 3 / 9 ) 8 8 . 0 ( 1 0 .4 ) 6 ( 6 / 6 ) 1 1 9 . 3 ( 5 .1 ) 6 .2 7 3 < 0 .0 0 1 5 4 - 5 9 m o n t h s 2 ( 2 / 6 ) 1 0 3 . 5 ( 2 6 .2 ) 5 ( 5 / 7 ) 1 1 9 . 0 ( 3 .3 ) 0 . 8 3 5 0 . 5 5 6 6 0 - 6 5 m o n t h s * * 3 ( 3 / 7 ) 9 9 . 7 ( 5 . 8 ) 6 ( 6 / 6 ) 1 1 5 . 8 ( 5 .6 ) 4 . 0 2 8 0 .0 0 5 6 6 - 7 1 m o n t h s 3 ( 3 / 5 ) 9 1 . 7 ( 1 5 . 5 ) 6 ( 6 / 1 0 ) 1 1 3 . 5 ( 2 .9 ) 2 . 4 1 4 0 .1 3 3 A l l s u b j e c t s ( 1 5 v s . 3 0 ) * * 9 7 . 0 ( 1 5 . 5 ) 1 1 9 . 2 ( 7 .7 ) 5 . 2 3 7 < 0 .0 0 1 Note. B o y s w i t h a u t i s m a r e t h e s e w h o h a s P P V T - R s t a n d a r d s c o r e h i g h e r t h a n 7 0 ( n = 1 5 ) . B o y s w i t h o u t d i s a b i l i t i e s a r e c h o s e n b y t h e r u l e t h a t e v e r y a u t i s t i c s u b j e c t is m a t c h e d w i t h t w o n o r m a l s u b j e c t s w i t h i n t h r e e m o n t h s o f a u t i s t i c s u b j e c t ’s c h r o n o l o g i c a l a g e ( n = 3 0 ) . *P< .0 5 . **P< .0 1 . As the results presented in Table 20 reveal, after excluding children with low PPVT-R scores, the mean scores of the subgroup of autistic boys still were significantly lower than those of the subgroup of normal boys on the PPS total score and three of its four dimensions (i.e., Material Management, Pretense/Symbolic, and Participation). Interestingly, when the comparison was made in terms of the subgroup of autistic boys with adequate intellectual capacity and their matched normal controls, the mean score of the two groups in Space Management was no Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 188 longer found to differ significantly in this secondary analysis. Thus, the autistic individuals with an adequate level of cognitive function scored at age-appropriate levels in their body manners, and there was no significant difference between the two subgroups in the way the subjects managed the space around them during play, as the dimension of Space Management measured. Although there was not a significant difference between the subgroups, particular caution should be taken when interpreting these results on the dimension of Space Management. Although typical actions, movements, and behaviors were observed among the subjects with autism, and contributed to the score granted at the age-appropriate level, the quality of the child’s motor coordination and ease of performance seemed very different from the typically developing children. Specifically, based on the information in the researcher’s memos, when compared with their peers, subjects with autism were more likely to demonstrate behavior that seemed to be qualitatively unusual. For instance, three children with autism in this study walked and ran on tiptoe with springy patterns of movement. Several children were active but tended to be clumsy in their movements, and they were observed to run with a non-fluid gait, they could not start and stop or accelerate and decelerate with good control. Moreover, for the motor activity involved in climbing such items as ladders, monkey bars, or the jungle gym, several children in this study showed difficulty in accurately positioning their feet and hands, and in planning the next move of actions. Two Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 189 children tried multiple times to get onto a seesaw and still failed to do so. Several children exhibited difficulty in the planning process of pedaling a tricycle, bicycle, or wagon, and prompting the swings to move. In the scoring, the behavioral descriptors (e.g., runs, walks, rides car, climbs, accelerates, or decelerates) were demonstrated by these children. Therefore, the scores were given at the age-appropriate level, regardless of the quality of their movements or behaviors. In addition, it is noteworthy that 57% of subjects with autism (21 out of 37) were rated at an 18-month level on the category of Interest in Space Management because they demonstrated restricted interest in exploring various kinesthetic and proprioceptive sensations while they played. For example, many children with autism engaged in such activities as jumping up and down on the mattress or on the floor, tumbling about on the floor or the mat, running around and self-spinning in a circle, hitting the wall with their palms, or throwing themselves into the therapeutic big ball. The autistic individuals commonly demonstrated unusual sensory behavior, hand and fmger mannerisms, and whole body mannerisms (Lord et ah, 1994). Unsurprisingly, a large amount of the subjects with autism in this study displayed self-stimulatory behavior in many ways, such as body rocking and self-spinning. Since many of the subjects with autism in this study focused their interests on activities or movement patterns involving kinesthetic and proprioceptive stimulations, they usually demonstrated an insufficient sense of danger and safety awareness while managing their bodies and the space around them at play, which could lead them into Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 190 perilous situations. For example, one child in this study saw a plastic bag fly away with the wind across the road, and he suddenly and unexpectedly ran towards it, crossing traffic, unaware of potential danger. Unfortunately, as the examples above reveal, such qualitative differences in the subjects’ behavior could not be captured and measured by the Space Management dimension in PPS. Therefore, this researcher suggests that PPS should be used in conjunction with the qualitative analysis of data (e.g., written field-notes, videotapes), or in conjunction with other assessments (e.g., play style, playfulness) to assess children’s play qualitatively and quantitatively. Also, this researcher strongly hopes to see professional success in the development of a sophisticated instrument that is able to elicit potential qualitative abnormalities at the observational/behavioral level. Summary When a comparison was made between the autistic subjects with adequate cognitive functioning and the controls, Taiwanese boys with autism had significantly lower scores on the PPS total play age and its dimension of Material Management, Pretense/Symbolic, and Participation. Based on the results, this researcher concludes that deficits in (a) the way the individuals manage their material surroundings, (b) the way the individuals learn about the world through their symbolic capacities, and (c) the manners the individuals use to interact socially with others, are distinguishable features of Taiwanese boys with autism at play. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 191 Performance o f Taiwanese Subjects without Disabilities As Table 12 demonstrated, the age scores on the dimension of Space Management and Material Management among Taiwanese boys without disabilities were significantly higher than their chronological age. Interestingly enough, although the difference just failed to reach significance, normal subjects had lower age scores on the dimension of Pretense/Symbolic and Participation, when compared to their chronological age. To give possible explanations, this researcher believes that cultural philosophies and “parental ethnotheories,” defined by Harkness and Super (1996), may have a strong influence on the play performance of Taiwanese children. Parents or adults from different cultures and backgrounds develop their own style of childrearing and parenting vitally influenced by their cultural philosophies and beliefs (Harkness & Super, 1996). Moreover, they have a unique understanding of, and value toward, the nature of children, and the way in which they interpret children’s behavior, and structure their children’s development. All these culturally linked conceptual understandings have been called the “parental cultural belief system” or “parental ethnotheories” by Harkness and Super (1996). Participation In the literature, people in Taiwan are more likely to demonstrate the organizational tendency of collectivism, which tends to emphasize social conformity and the obligations of the self to the community: valuing loyalty, trust, and filial Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 192 piety; respecting the old and obeying authority, adhering to rules and the virtue of submission and cooperation (Chao, 1994; Hofstede, 1983; Triandis, 1991). As a result, the aim of education and successful parenting and childrearing is to raise and foster children who are capable of maintaining a harmonious “interdependent self,” as termed by Markus and Kitayama (1991), who can fit in well and become a part of various interpersonal relationships that develop similarity and connectedness with others. When the children’s level of social interaction and ability to get along with others in play are rated on the dimension of Participation, as presented in literature, the Taiwanese subjects without disabilities were expected to score at the age- appropriate level. However, 52% of the normal subjects (22 out of 42) had lower age scores than their chronological age on the dimension of Participation. This result might be attributed to the normal subjects’ decreased score in the category of Humor in the dimension of Participation. Interestingly, normal subjects in this study scored much lower in the Humor category relative to their chronological age, and the difference reached significance at a reduced level ip < 0.01). Only 24% of the normal subjects (10 out of 42) were rated at age-appropriate levels or higher levels than their chronological age in the category of Humor. The mean score on the dimension of Participation of the Taiwanese subjects without disabilities decreased as a result of their poor performance in the category of Humor. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 193 In Taiwanese society, children are taught well-known aphorisms like “Silence is golden” or “The mouth is the source o f calamities,” which highly emphasize the virtue of self-restraint. Thus, they might be discouraged to use language freely in their humorous expression. Also, Taiwanese children are taught the cultural understandings and expectations for appropriate behavior in early childhood; and specifically, adults do not appreciate children speaking “nonsense,” or acting “silly,” deliberating distortions of meaning, exaggerating incongruous actions or events, or violating the rules of propriety. Under the influence of cultural philosophy and parental ethnotheories, this researcher believes that the Taiwanese children might not be able to appreciate humor and might rarely demonstrate humorous expression. Therefore, it was understandable that the behavioral descriptors of the Humor category at a more mature age level, such as making odd sounds intentionally, exaggerating facial expressions, responding toward incongruous concepts, making distortions of the familiar, laughing at nonsensical words, or laughing at multiple meanings of words, were not be observed in Taiwanese subjects without disabilities, as such behavior would be improper in Taiwanese society. Pretense/Symbolic The dimension of Pretense/Symbolic measures children’s capabilities of imagination in pretend play and symbolic representation of reality (Knox, 1997). As can be seen in Table 12, although the difference did not reach a significant level, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 194 normal subjects had lower age scores when compared to their chronological age on this dimension, 52% of the normal subjects (22 out of 42) obtained lower age scores on this dimension than their chronological age. The cultural philosophies and parental ethnotheories toward creativity, flexibility of thought, and the incongruity of reality and make-believe, might explain this result. As noted in the literature, children in Taiwan are raised with the collectivist nature of self-development to avoid becoming autonomous and separate from others (Markus & Kitayama, 1991). The highest regarded learning philosophy within Taiwanese society is to view authority as a repository of knowledge and children as vessels to be filled. Thus children are expected to be educated about culturally defined knowledge through adult-directed instruction, and to accept this knowledge without question and with an obedient attitude (Ho, 1994). Also, children’s exploratory demands and divergent thinking tend to be discouraged (Liu, 1986). Moreover, traditional Taiwanese parents are more likely to be identified as holding “authoritarian” parenting beliefs: parents freely assert their power, expect obedience, attempt to instill respect for authority, and rely on orders rather than reasoning (Liu, 1986). Under the influence of cultural philosophies and parental ethnotheories, this researcher believes that Taiwanese children are more likely to be quiet, compliant, and obedient. They are less likely to demonstrate self-centered characteristics such as autonomy, enriched interests, creativity, innovation, divergent reasoning, the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 195 ability to take initiative and be assertive, unique expression, and exaggerated imaginary logic. Additionally, in this researcher’s experience, behaviors like non disciplined actions, “out-of-bounds,” make-believe, deliberate distortions of the realistic meaning of imagination, pretending, incongruous invention, fictitious deformations of the real world, are discouraged, and often are prohibited and corrected. Hence, this researcher believes that children might be punished when they show a distorted realm of reality or violate cultural expectations. As understood, the dimension of Pretense/Symbolic was designed to capture the children’s capacity of mirroring aspects of cultural environment, separating reality from make-believe, creating role play, and elaborating routine themes (Knox, 1997). Knowing such behaviors are restricted by cultural regulations, it was not surprising to find that about half of the Taiwanese subjects without disabilities (i.e., 52%, n=22) scored at a lower age level than their chronological age on this dimension. Material Management The dimension of Material Management measures the manner in which children manipulate and combine materials in fine motor play (Knox, 1997). The good performance of children without disabilities in this dimension might be attributed to children’s increased access to more constructive play materials arranged by their parents. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 196 In Asian societies such as, Japan, Taiwan, and China, parents highly emphasize academic performance in children (Tobin et al, 1989). Specifically, Taiwanese parents tend to judge children’s success with a narrow focus on academic achievement (Chang, 2001). Taiwanese mothers believe play contributes most to children’s cognitive development and they are more likely to arrange constructive play situations with a variety of toys (e.g., shape-sorters, interlocking blocks, Legos, two- or three-dimensional puzzles). Taiwanese mothers highly encourage children’s engagement in arithmetic and alphabetic play, which require mature cognitive participation (Pan, 1994). These mothers believe the arrangement of constructive activities can foster children’s cognitive development, and that later on, the children may benefit from such play and demonstrate higher academic achievement (Pan, 1994). As noted, Taiwanese parents predominantly believe that children’s engagement in constructive activities and manipulating constructive toys are closely linked to their cognitive development. Therefore, it is not difficult to believe that Taiwanese children have plenty of opportunities and spend a considerable amount of time engaged in constructive play arranged by their parents. In turn, it was not surprising that the normally developing Taiwanese subjects performed well on the dimension of Material Management. In other words, the children’s capabilities of manipulating and constructing objects in a mature and complex control, and their ability in orienting well-planned, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 197 specifically-designed, and complex-organized, have been highly facilitated and integrated into children’s play by Taiwanese parents. In this study, it could be inferred that the subjects without disabilities obtained high scores on Manipulation, Construction and Purpose due to parents’ predominant emphasis on cognitive- oriented philosophies in Taiwanese society. Space Management This researcher believed that the high scores obtained by the normal children in this dimension was appropriate because these Taiwanese children were “free” in their play, and they played in familiar environments with no restrictive supervision from adults. All the subjects were told to play in any way they wanted, and the supervising adults were not to interfere in the children’s play. With all their freedom and autonomy, these children demonstrated the behavioral descriptors of the mature level of PPS. Their ability to engage in activities with an increased energy level, to attempt exaggerated movements, and to carry out aggressive play with more coordinated physical skills rated them at a higher age level in this dimension. Application o f PPS in the Taiwanese Population Subsequently, this researcher would like to address one important question: To what extent is the Revised Preschool Play Scale (PPS) applicable and reliable in evaluating the play capacity of the Taiwanese population? Based on this study, although analyses supported the appropriateness of PPS utilization in the Taiwanese Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 198 population, this researcher suggests that caution be taken when interpreting results, as they could be slightly modified. Direct Administration o f PPS in Taiwanese Population This researcher feels comfortable recommending the direct use of PPS to assess play in Taiwanese children. In this study, the correlation analyses indicated that the scores of children on all categories (with the exception of Attention) in PPS significantly correlated with their chronological age in children without disabilities. In addition, there was a significantly higher correlation between chronological age and PPS total play age and dimension scores with the normally developing group than with the group of children with autism (Table 16). The correlation between chronological age, PPS total play age, and dimension scores in the boys without disabilities was found to be at an acceptable level, and these correlations were significantly higher in the normal group than in the autistic group. These correlation analyses allowed the researcher to infer that PPS behavioral descriptions/factors do reflect or relate to sequential play development among the normally developing Taiwanese population, and thus support the applicability o f PPS in the Taiwanese population. Furthermore, discriminant analyses indicated that the age scores on the PPS and on each of its four dimensions correctly predicted the subjects’ group membership (Table 19). However, the score from the dimension of Material Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 199 Management was only a fair predictor of group membership, which correctly classified 67% of subjects, and this classification rate was only slightly greater than chance (i.e. 50%). Overall, however, this researcher considered PPS to be a good instrument in differentiating and categorizing children with autism and children without disabilities in the Taiwanese population. Although the findings from the correlation and discriminant analyses strongly pointed to the acceptable applicability of PPS in the Taiwanese population, some problems still remained unsolved. Thus scores, such as for the dimension of Material Management, should be interpreted with caution. Interestingly, every Taiwanese subject without disabilities and 34 out of 37 subjects with autism in this study attained the ceiling level of Attention performance in PPS. As discussed earlier, Attention in PPS only assessed the length of time a child independently occupied himself in play, which did not capture all the properties of a person’s attention capacity. The score on the Material Management section was calculated from each of the four categories’ scores, and since the high score in Attention contributed considerably to the dimension score of Material Management, this score should be interpreted with particular caution. Modification and Refinement o f PPS fo r Taiwanese Population Considering how children’s behavior is orchestrated and shaped by national tradition and cultural philosophies in various contexts, professionals in the pediatric Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 200 practice certainly are encouraged to modify and refine the PPS for the Taiwanese population. Since no study has been conducted to indicate the reliability and validity of PPS within the Taiwanese population, professionals might want to administer PPS on a considerable amount of Taiwanese children to determine the appropriateness of each category. Certain categories may need to be modified or replaced. Based on the data in this study, attention should be given to modifying PPS measures in accordance with cultural meanings and values. The modification might be done by revising the actions/descriptors under each category with more culturally relevant factors. The scale could be refined by clearly defining the actions/descriptors or providing concrete examples of abstract descriptors, in order to avoid the ambiguity of wording and to assist a rater’s judgment of identical behaviors in scoring. Develop a New Assessment for Taiwanese Population As pointed out, children’s play is shaped by cultural contexts. In this regard, this researcher encourages professionals in Taiwan to take initiative and devote their selves to developing a standardized instrument that conveys Taiwan’s own cultural spirit and attempts to conceptualize the play performance of the Taiwanese population. To achieve this goal, a great deal of research must be conducted. For example, professionals need to identify the normative behaviors, systematically describe the acquisition of normative behaviors, and explicitly frame the behaviors in terms of the normative trajectories of development. Next, the procedures of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 201 administration and instructions for scoring should be set in a standardized fashion, and the norm-referenced data/ table with a specific age range should be established. Finally, the studies examining reliability and validity of the instrument should be conducted within the targeted population, such as individuals in specific cultures, individuals with a certain range of age, and individuals with specific diagnoses. Limitations As this study appears to provide comprehensive knowledge of the play performance of both normal and autistic subjects, some issues arise regarding the implications of the research findings. First of all, the restricted generalization of the study results should be mentioned. This study recruited 79 Taiwanese boys (i.e., autistics=37, normals=42), aged 3-5 years, from the urban area of Tainan City. The children met the eligibility criteria of being a subject with autism or a subject without disabilities, and the children’s parents or legal guardian consented to the children’s participation in the study. The study’s sample was not representative of the full population of children in Taiwan. Therefore, results cannot be generalized with confidence. Additional research needed to be done to find out if the findings are the same. Second, the procedure used to adequately match the target and contrast groups was of vital importance in determining the methodological validity of the study. In this study, the researcher initially matched subjects only on the basis of their chronological age (CA), but not on their IQ or MA (mental age). Given the Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 202 absence of adequate IQ, MA, or verbal communication ability matching of groups, the findings should be viewed as preliminary due to the priori group of differences in subjects’ general level of cognitive functioning. Third, videotaped observation was chosen as the preferred method of data collection for reasons that were described in the previous chapter. However, the use of videotaping for data collection also had some disadvantages. From the researcher’s experience, it was difficult to minimize videotaping disturbances in natural settings inhabited by numerous children, especially for the children without disabilities. Commonly among the normal subjects, the children demonstrated so much interest in the video camera’s presence that their performance was sometimes affected. More specifically, some children exhibited exaggerated behaviors whereas others showed decreased/withdrawal movement. This happened mainly with the peers who were present in the neutral environment during observation of the targeted subject. In the researcher’s experiences, longer warm-up sessions and good communication ahead of time was very helpful in decreasing the influence of the video camera on the subject’s behavior. Also, it is worth noting that this researcher spent a considerable amount of time persuading the parents to permit their children to be videotaped, and assuring the secure confidentiality of the videotapes, especially for the parents of the children with autism. The loss of recruitment due to videotaping should be considered (Spoth & Redmond, 1992). As noted in the description of final samples, several parents of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 203 non-participants felt offended and would not allow their children be videotaped, which resulted in their refusal to participate. These may have been bias that affected results. For example, perhaps, these parents do not want their children to be videotaped is because their children are very low functioning. Fourth, although the PPVT-R seems to be designed appropriately for the speech impaired individuals and also has been highly recommended for administration on autistic persons (Dunn, 1965; Dunn & Dunn, 1981; Lu & Liu, 1998), it was found to be very difficult to administer the test to the autistics in this study. Briefly speaking, 35% of autistic subjects were un-testable and 16% of autistic subjects completed the test only with assistance from a supervising adult. In this researcher’s opinion, the companionship and assistance of a supervising adult should be arranged in order to elicit the subject’s compliance and cooperation. Reinforcement (e.g., favorite foods or toys) may be helpful, and a longer period of time should be anticipated to complete the test administration in subjects with autism. Particular caution should be given while interpreting subjects’ performances on PPVT-R. The PPVT-R score cannot be interpreted as the subject’s general cognitive level of intelligence due to its limited scope, which measures only receptivity. Indeed, there are various domains of development for receptive and expressive language, such as vocabulary comprehension, pragmatics recognition, referential meanings of language (e.g., words usage in association with particular objects), combinational meaning of language (e.g., words’ combination into Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 204 sentences in meaningful ways), or intentional meaning of language (e.g., intonation or stress detection) (Paul & Cohen, 1984). Thus, even though receptive vocabulary ability is related to general intelligence, the good scores on PPYT-R in some subjects with autism did not indicate their intellectual levels of functioning and language usage in real-life communication. Moreover, special care must be taken in interpreting the functioning in these subjects with autism who cannot be tested (i.e., n=13, 35%). Since certain capacities of examinees, such as adequate hearing and visual abilities, acceptable sustained attention, as well as the ability to indicate yes or no in a recognizable manner are required to successfully complete the PPVT-R test, autistic subjects who exhibited impairment in any related capacities might be seriously penalized by this test. Thus, their inability to be tested should not be assumed to always indicate a deficit in the particular facet of ability repertoire as measured by PPVT-R. Suggestions fo r Future Research Overall, this study provides the preliminary understanding of children’s play in Taiwan. It also raises a number of concerns that can be investigated in future studies. The following section addresses these concerns in some detail. IQ, MA, or Other Criteria on Group Matching The first direction for future research is to study a broader representation of the population. The present findings from this study must be viewed as preliminary until replicated in studies with more representative groups of persons with autism Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 205 and with more careful and precise matching with comparison groups. In this study, a significantly low level of cognitive functioning (as measured by PPVT-R) was found in subjects with autism. There is a need to carefully replicate the study procedures with autistic children at different levels of cognitive ability (from profoundly retarded through normal intelligence) and to adequately match the participant groups, in order to make meaningful comparisons. Gender Variable Gender is a crucial variable, which might affect how a child behaves in play. In order to broaden the understanding of play functioning among children with autism, there is a need to examine the behavioral differences or similarities (e.g., motor or physical play, social participation, object play, pretense patterns, imaginary play, language use, and activity preferences) among autistic population. Longitudinal Research There is as of yet no research completed about whether the play of children with autism changes over long periods in Taiwan. In the literature, play in children with autism may be presented differently at different ages or levels of development. Some autistic preschoolers may display a great deal of motor activity in play in their early childhood, and then might become gradually less active while remaining inattentive or distractible as they grow older (DeMyer et ah, 1973; Lord et al., 1996; Lotter, 1974, 1978; Rutter, 1970). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 206 The capabilities in some autistic individuals gradually improved with age and they appeared to function optimally by the time the autistics reached their middle childhood, later childhood, or adolescence (DeMyer et a l, 1973; Lord et al, 1996; Lotter, 1974, 1978; Rutter, 1970). Therefore, there is a need to conduct a longitudinal follow-up study throughout the lifespan of the subjects in order to understand the developmental trajectories in an individual with autism at play. Cultural, Environmental, and Human Contexts The content and themes of children’s play may differ across cultures. Children absorb the prevailing cultural images and attitudes that reflect their cultural heritage of beliefs and values. As discussed, the cultural philosophy and parental ethnotheories (e.g., the opportunities of play participation, the variety of play contexts, parenting styles, and childrearing goals) may affect play performances of children. Thus, it is important for researchers to examine the potential influence of cultural factors in children’s play. Studies should be conducted to address children’s play in different cultural, environmental, and human contexts, in order to understand how the contexts affect children’s play development, play styles and performances. Thus, there is a need to consider the meaning of play in a child’s own culture as well as a need to examine how play contributes to the development of the way children adapt in their dominant cultures. It is also important to observe play in children with autism in a variety of settings, (school, home, neighborhood, structured, unstructured, clinic, outdoors, indoors) within different levels of familiarity and complexity in Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 207 their environment, according to the degree of structure demanded, or to the number of peers or adults present. Playfulness Another direction for future research in play among children with autism is to examine it alongside other related areas, playfulness, for instance. In conjunction with PPS, the consideration of the degree of involvement and enjoyment in play, playfulness, would strengthen the comprehensive understanding of play in children with autism. Over the decades, a number of researchers have devoted themselves to the field of autism, and have provided evidence and numerous findings regarding the play development of individuals with autism. However, very rarely have studies concerning the enthusiasm and enjoyment of autistic children at play been conducted. In recent years, it has been a contemporary trait to extend the traditional research strategies to emphasize a child’s internal state by focusing on the individual’s predisposition toward extraneous encounters in play (Barnett, 1990 & 1991, Bundy, 1997). More recently, researchers are beginning to readjust critical thinking about the nature of play to focus on the underlying characteristics of a child’s internal predisposition (Barnett, 1990 &1991; Bundy, 1997). There is a need to capture the essence of the predisposition, as well as a need to understand how this essence might be laid out, in concordance with other factors. The consideration of play skills among autistic children in relation to their internal disposition of Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 208 playfulness can only serve to broaden thoroughly the knowledge of play in children with autism. Conclusion Occupational scientists tend to approach individuals in a holistic sense as an occupational being. It is vital to understanding the form, function, meaning, and context of the individual’s daily engagement, how the individual shapes the dynamic relationship with people around, and the individual’s attribution to the adaptation and the quality of his own life and others as well. In this study, children’s most essential occupation (i.e., play) was examined. This study examined the play performance in children with autism and without disabilities within Taiwan society. As noted, children with autism displayed difficulties across a range of developmental domains in play, rather than in simply only one or few specific areas, which added additional support to the wide range of the impairments associated with autism. Children with autism demonstrated certain types of deviations, abnormalities, rates, and patterns of development in play, which might not lie on the normal pathways of human development. Autism is a severe and a lifelong disability, and children with autism might never become fully normal and require at least some assistance throughout their lives. There is a pressing need to provide the social network, family resources, and coping strategies to facilitate the successful adaptation in children with autism. In addition, Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 209 it is also important to enhance the community acceptance, and public support of children with autism and their families. In sum, the evidence and findings in this study are intended to broaden readers’ understanding of play performance in normal children and the potential difficulties autistic children may encounter in play within Taiwanese society. In Taiwan, the lack of research on autism, from perspective of occupational science and occupational therapy, is disappointing. It is hoped that the data and findings from this study can serve as the preliminary baseline for further study, and then to inspire more professionals in the field of occupational science and occupational therapy devote themselves to address the play in individuals with autism. It is also hoped that these research findings might further facilitate the international sharing and exchanges of knowledge in the field of autism and that the comparative analysis can be applied cross-nationally to broaden and expand the professional perspective worldwide. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 210 REFERENCES Alessandrini, N. A. (1949). Play: A child’s world. American Journal o f Occupational Therapy, 3, 9-12. American Psychiatric Association. (1952). Diagnostic and statistical manual o f mental disorders (1st ed.). Washington, DC: Author. American Psychiatric Association. (1968). 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Integrated play groups: A model for promoting the social and cognitive dimensions of play in children with autism. Journal o f Autism and Developmental Disorders, 23, 467-489. World Health Organization. (1993). The ICD-10 classification o f mental and behavioral disorders: Diagnostic criteria fo r research. Geneva: Author. Wulff, S. B. (1985). The symbolic and object play of children with autism: a review. Journal o f Autism and Developmental Disorders, 15, 139-148. Zillmann, D. (1987). Mood management: Using entertainment to full advantage. In L. Donohew, H. Sypher, & T. Higgins (Eds.), Communication, Social Cognition, and Affect (pp. 147-171). Hillsdale, NJ: Erlbaum. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 231 APPENDIX A INTERNATIONAL CLASSIFICATION OF DISEASES (ICD-10): CRITERIA FOR AUTISM H 84.0 C hildtoad Autism A. Abnormal of impaired development is evident before the age of 3 years in at least one of the following areas:' (1) receptive or expressive language as used in social communication; (2) the development of selective social attachments or of reciprocal social interaction; (3) functional or symbolic play. B. A total of at least six symptoms from (1), (2), and (3) must be present, with at least two from (1) and at least one from each of (2) and (3): (1) Qualitative impairments in social interaction are manifest in at least two of the following areas; (a) failure adequately to use eye-to-eye gaze, facial expression, body postures, and gestures to regulate! social interaction; (b) failure to develop ( in a manner appropriate to mental age, and despite ample opportunities) peer re lationships that involve a mutual sharing of interests, activities, and emotions; (e) lack of soeioeniotional reciprocity as shown by an impaired or deviant response to other people's emotions; or lack of modulation of behavior according to social context; or a weak integration of so—■ cial, emotional, and communicative behaviors; (d) lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., a lack of showing, bringing, or pointing out to other people objects of interest to the individual). (2) Qualitative abnormalities communication as manifest in at least one of the following areas: (a) delay in, or total lack of, development of spoken language that is not accompanied by an attempt to compensate through the use of gestures or mime as an alternative mode of communication (often| preceded by a lack of communicative babbling); (b) relative failure to initiate or sustain conversational interchange (at whatever level of language skill is present), in which there is reciprocal responsiveness to the communications of the other person; ; (c) stereotyped and repetitive use of language or idiosyncratic use of words or phrases; (d) lack of varied spontaneous make-believe play or (when young) social imitative play. (3) Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities are manifested in at least one of the following; (a) an encompassing preoccupation with one or more stereotyped and restricted patterns of interest that; are abnormal in content or focus; or one or more interests that are abnormal in their intensity and cir cumscribed nature though not in their content or focus; (b) apparently compulsive adherence to specific nonfunctional routines or rituals; (c) stereotyped and repetitive-motor mannerisms that involve either hand or finger flapping or twisting, or complex whole-body movements; (d) preoccupations with part-objects or nonfunctional elements of play materials (such as their odor, the feel of their surface, or the noise or vibration they generate). C. The clinical picture is not attributable to the other varieties of pervasive developmental disorders; specific development disorder of receptive language (F80.2) with secondary socioemotional problems’ reactive at tachment disorder (F94.1) or disinhibited attachment disorder (F94.2); mental retardation (F70-F72) with some associated emotional or behavioral disorders; schizophrenia ( F2Q.-) of unusually early onset; and Rett’s Syndrome (F84.I2). 1 F r o m ICD-10 Classification o f Mental and Behavioral Disorders: Diagnostic Criteria for Research (pp. 1 4 7 - 1 5 0 ) , b y W o r l d H ealth Organization, 1 9 9 3 , Geneva; W o r l d H e a l t h O r g a n i z a t i o n . C o p y r i g h t 1 9 9 3 b y t h e W o r l d H e a l t h O r g a n i z a t i o n . R e p r i n t e d w i t h p e r m i s s i o n . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 232 -.-134.1 M y p ie a l A w lis® A. Abnormal or impaired development is evident at or after the age of 3 years (criteria as for autism except for age of manifestation). B. There are qualitative abnormalities in reciprocal social interaction or in communication, or restricted, repet itive. and stereotyped patterns of behavior, interests, and activities. (Criteria as for adtism except that it is unnecessary to meet the criteria for number of areas of abnormality.) C. The disorder does not meet the diagnostic criteria for autism ( F84.0). Autism may be atypical in either age o I onset (F84.I0) or symptomatology (F84.1 I ); the two types arc differen tiated with a liith character lor research purposes. .Syndromes that are typical in both respects should be coded F84.I2. F84.10 A ty p ic a lity in age o f onset A. The disorder does not meet criterion A for autism (F84.0); that is. abnormal or impaired development is evi dent only at or after age 3 years. ff. The disorder meets criteria B and C for autism (F84.0). FS4.II A typ icality in sym ptom atology A. The disorder meets criterion A for autism (F84.0); that is, abnormal or impaired development is evident be fore age 3 years. B. There are qualitative abnormalities in reciprocal social interactions or in communication, or restricted, repet itive, and stereotyped patterns of behavior, interests, and activities. (Criteria as for autism except that it is unnecessary to meet the criteria for number of areas of abnormality.) C. The disorder meets criterion C for autism (F84.0). D. The disorder does not fully meet Criterion B for autism (F84.0). F84.12 A typ icality in both age of on set and sym p tom atology A- The disorder does not meet criterion A for autism (F84.0); that is, abnormal or impaired development is evi dent only at or after age 3 years. B. There arc qualitative abnormalities in reciprocal social interactions or in communication, or restricted, repet itive, and stereotyped patterns of behavior, interests, and activities. (Criteria as for autism except that it is unnecessary to meet the criteria lor number of areas of abnormality.) C. The disorder meets criterion C for autism (F84.0). ■ I), The disorder stews sat fuHy meet etiterfo# B far autism (FW.SJ. From 1CD- / 0 Classification o f M ental and Behavioral Disorders: Diagnostic Criteria fo r Research (pp. 147-150), b y W o r ld . H e a l t h O r g a n i z a t i o n , 1 9 9 3 , G e n e v a : W orld H ealth O r g a n i z a t i o n . C o p y r i g h t 1993 by the W orld H ealth Organization. R eprinted with perm ission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 233 APPENDIX 1 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV): CRITERIA FOR AUTISTIC MSOMDIM ■ W a f a e u t i c c r i f o f t o f o r 299.00 A a t b t l c D b o f d s r A. A total of six im more! ta n s from <1), (3), asd (}), with su te st two fm srn {II, and a n t eacfi from {21 and < 3 > : !1) qualiMiw in social imramsicw, as manifested by at lost w o a t tb® Mowing: <ai marked to tlw u « of mukipiem »voiwlbrf»vi»» such as eytMo-eye g its, facial ®Jtjxe»tart, body pustules, and gestures u> re-gutat® .uicia! imefMiiii® ihl failure ut develop poor islatkmihips appropriate m i dcvekip- « n « al level (c) a iacfc (if Spomasseota wetting to stains enjoyfnent, interests, or achievements with other people (e.g., by a lack at showing, bringing, or pointing out objects of interest) id) tack of social or emutional reciprocity i 2i qualitative impairments in communication as manifested by at tew a m of til® foUowtng: (a) delay in, or total lads at, the development of spoken language (not acvompanieti by an attempt to compensate through aiiensaiiwf modes of communiotioo such as gem*® or mime) ib> in individuals with adequate speech, marked impairment in the ability to initiat® or sustain a ctmvmaiion with tghcni tv I stereotyped and repetitive use «rf language or Uiusyncmitc language fttt lads at varied. xptm m 6m u moke-Mie*® pby or sositi imitative pfay appropriate so devefcapmeraal iewi (amrtmtmit □ A srB p B cB liW fsto fittsssM a ssfl (31 nmtrkxnl repetkiwamSifctagyiitsI patterns (il'Mwriw, immstss, and aesivitiat, » manifested by at least one at (lie fallowing: (a> etarnisMMmg preoccupation with <ms or urnre stereotyped awl osrtrktwl patterns of interest dial is atamimai either in intensity or fiu a (M apparently tnfkstble adherence m specific, nonjundional routine!* m rituals (c) sferetxyped ami repetitive motor mnneriains (e.g., ham) or finger (lapping or twisting, or complex whoie-hody muve- metws) idi pevxixfent preoccupation with pans uf tthjccts 0. Delays or abremnal ftmatoning in at test one at the following a m , with omet prior to age 3 years: (i) social interaction, (21 tagstag® ax used in social ctimnsunicasiim, or (3) symhtsiie or imaginative play. C. "file (Itsturixince « tux heaer accounted for by ten's DiMirdcr or C hjldtM K isI Disintegrative Disorder. From Diagnostic and Statistical M anual o f Mental Disorders, Fourth Edition (pp. 70-71), by American Psychiatric Association, 1994, W ashington, DC: American Psychiatric Association. Copyright 1994 by the American Psychiatric Association. Reprinted with permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 234 APPENDIX C REVISED KNOX PRESCHOOL PLAY SCALE (PPS) • MtMnlfc* ttalHManrt* n » l ® 8 S® ssts§ Space management Gross motor: swipes, reaches, plays with hands and feet, moves to con tinue pleasant sensations Interest: people, gazes at faces, follows movements, attends to voices and sounds, explores self and objects within reach Gross m otor, reaches in prone, crawls, sits with balance, able to play with toy while sitting, pulls to stand, cruises Interest: follows objects as they disap pear, anticipates movement, goal- directed movement Gross m elo n stands unsupported, sits down, bends and recovers balance, walks with wide stance, broad movements involving large muscle groups, throws ball Interest: practices basic movement patterns, experiments in movement, explores various kinesthetic and proprioceptive sensations, moving objects (i.e., balls, trucks, pull toys) Material management Manipulation: handles, mouths toys, bangs, shakes, hits C om tnjction: brings two objects to gether Purpose: sensation— uses materials to see, touch, hear, smell, mouth Attention: follows moving objects with eyes, 3 to $ sec attention Manipulation; palls, turns, pokes, tears, rakes, drops, picks up small object C onstruction: combines related ob jects, puts object in container Purpose action to produce effect, cause and effect toys Attention: 15 sec for detailed object, 30 sec for visual and auditory toy Manipulation: throws, inserts, pushes, pulls, carries, turns, opens, shuts Construction: stacks, takes apart, puts together, little attempt to make product, relates two objects appro priately (i.e., lid a n pot) Purpose: variety o f schemas, process important, trial and error, relational play Attention: rapid shifts P r e ts w /a f a jM k imitation: o f observed facial expres sions and physical movement {i.e., smiling, pat-s-eakc), imitates vocal izations Dramatization: not evident Im itation: imitates observed actions, emotions, sounds and gestures not part of repertoire, patterns o f famil iar activities Dramatization: not evident Imitation: o f simple actions, present events and adults, imitates novel movements, links simple schemas (Le., puts person in car and pushes it) D ram atization: beginning pretend us ing self (i.e., feeds self w ith spoon), pretend on anim ated an d inarai- m ated objects Participation Type: solitary, no effort to interact with other children, enjoys being picked up, swung Cooperation: demands personal atten tion, simple give and take interac tion with caretaker (tickling, peek- a-boo! Humor: smiles Language: attends to sounds anti voices, babbles, uses razzing sounds Type: infant to infant interaction, re sponds differently to children and adults Cooperation: initiates games rather than follows, shows and gives ob jects H utnon smiles, laughs at physical games and in anticipation Language: gestures intention to com municate, responds to familiar words and facial expressions, re sponds to questions Type combination o f solitary and on looker, beginning interaction with peers Cooperation: seeks attention to self, demands toys, points, shows, offers toys but somewhat possessive, per sistent Humor, laughs at incongruous events Language: jabbers :o self during piay, uses gestures and words to com mu nicate wants, labels objects, greets others, responds to simple requests, leases, exclaims, protests, combines words and gestures From Play in Occupational Therapy fo r Children (pp. 47-49), by D. Parham and L. Fazio (Eds.), 1997, St. Louis: M osby. Copyright 1 9 9 7 b y t h e M o s b y / E l s e v i e r . Reprinted with permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 235 is to 14 241 o JS month* x»3t Space management Grass m otor: rum , squab, climbs on and off chairs, walla up and down Hairs (step so gait), kicks ball, rides kiddy car Interest: means— end, multipart tasks Gross m otor: beginning integration o f entire body in activities— concen trates on complex movements, jumps off floor, stands on one foot briefly, throws ball in stance with out falling Interest: explores new movement pat terns (i.e., jumping), makes messes Gross motor: runs around obstacles, turns com ers, climbs nursery appa ratus, walks up and down stairs (al ternating feet), catches ball by trap ping it, stands on tiptoe Interest: rough and tumble play Material ManagMMRt Mantpsilalisin: operates mechanical toy, pulls apart pop beads, strings beads C onstruction: uses tools Purpose: foresight before acting A ttention: quirt play 5 to 10 min; play with stogie object 5 min Manipulation: feels, pats, dumps, squeezes, fills Construction: scribbles, strings beads, puzzles 4 to 5 pieces, builds hori zontally and vertically Purpose: process important— less in terested in finished product (i.e., scribbles, squeezes), plans actions Attention: intense interest, quiet play up to 15 min, plays with single ob ject or theme 5- S O min Manipulation: matches, compares Construction: muitischeme com bina tions Purpose: toys with moving parts (Le., d u m p tru d o , jointed dolls) Attention: 15 to 30 min P m eosektym ixrfic Imitation: representational, recognizes ways to activate toys in imitation, deferred imitation Oraiaatisarion: acts on doil (i.e.. dresses, brashes hair), pretend ac tions on m ore than one object or person, combines two or m o te ac tions m pretend, imaginary objects Imitation: o f adult routines with toy - related mimicry (i.e., child feeding doil); imitates peers, representa tional piay B raaalization: personifies dolls, stuffed animals, imaginary friends, portrays single character elaborates daily events w ith details Im itation: toys as agents { « ., doll feeds self) m ore abstract representa tion o f objects, multischeme com bi nations (Le., feed d o i, pat it, po t to bed) Dramatization: evolving episodic se quences (i.e., mixes cake, bakes it, serves it) Participation Type: onfooker, simple actions and contingent responses between peers Cooperation: more complex games with a variety of adults {hide and seek, chasingS, com m ands others to earn' out actions Humor: laughs as incongruous label ing o f isbjgess or events Language: comprehends action words, request.-, information, refers to per- and ubjccis not present, com bines words toticther Type: parallel (plays beside others but play remains independent), enjoys the presence of others, shy with strangers Cooperation: possessive, m uch snatch and grab, hoarding, no sharing, re sists toys being taken away, inde pendent, initiates own play Human laughs at simple combina tions o f incongruous events and use o f words language: talkative, very little jabber, begins to use words to com m uni cate ideas, information, questions, com m ents on activity Type: parallel, beginning associative, plays with 2 to 3 children, plays in company 1 to 2 hr : understands needs o f others Humor: laughs at complex combina tions o f incongruous events and words Language: asks wh- questions, relates temporal sequences From Play in Occupational Therapy fo r Children (pp. 47-49), by D. Parham and L. Fazio (Eds.), 1997, St. Louis: Mosby. C o p y r i g h t 1997 by the M o s b y / E I s e v i e r . R eprinted with permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 236 MmMMmtks Space management Gross m otor: m ors coordinated body m ovem ent, smoother waiting, jum ping, climbing, running, accel erates, decelerates, hops on one foot 3 to 5 tiroes, skips on one foot, catches b a it throws bail using shoul der and elbow, jumps distances Interest: anything new, fine motor marsipuiaiion o f play materials, challenges self with difficult asks Material management Manipulation: small muscle activity— hammer*, sorts, inserts small ob jects, cuts C o m irnrtion: m a te simple products, combines play materia is, takes apart, three-dimensional, design evident Purpose: beginning to show interest in finished product Attention: span around 30 min, plays with single object or them 10 min Pretense/symbolic im itation: more complex imitation of real world, emphasis on domestic play and animals, symbolic, past ex periences Dramatization; cam ples scripts for pretend sequences in advance, story sequences, pretend with replica toys, uses one toy to represent another, portrays multiple characters with feelings {mostly anger and crying), little interest in costumes, imagi nary characters Participation Type: associative play, no organization to reach a common goal, more interest in peers than activity, enjoys companions, beginning cooperative play, group play Cooperation: limited, some turn tak ing, asks for things rather than grab bing, little attem pt to control others, separates easily, joins others in play Humor: laughs at nonsense wards, rhyming Language: uses words to communicate with peers, interest in new words, sings simple songs, uses descriptive vocabulary', changes speech depend ing nn listener 4t » M Month* Gross m otor: increased activity level, can concentrate on goal instead o f move ment, ease o f gross motor ability, stums, tests of strength, exaggerated movement, clambers, gallops, dimhs ladder, catches bail with elbows at side Interest: takes pride in work (i.e., shows and talks about products, compares with friends, likes pic tures displayed), complex ideas, rough and tum ble play____________ Manipulation: increased fine motor control, quick movements, force, pulling, yanks Construction: m a te products, spe cific designs evident, builds com plex structures, puzzles 10 pieces Purpose product very important and used to express self, exaggerates Attention: amuses self up t o ! hr, plays with single object or theme 19to ISmin Imitation: pieces together new scripts of adults (i.e., dressup), reality im portant Dramatization: uses familiar knowl edge to construct a novel situation {i.e., expanding on them e o f a story or TV show), role playing for or with others, portrays more complex emotions, sequences stories, themes front domestic to magic, enjoys dressup, shows off Type cooperative, groups o f 2 to 3 or ganized to achieve a goal, prefers playing with others to alone, group games with simple rules Cooperation: takes turns, attempts to control activities o f others, bossy, strong sense of family and home, quotes parents as authorities Humor: distortions of she familiar Language: piavs with words, fabricates, long narratives, questions persistently, communicates with peers to organize activities, brags, threatens, downs, sings whole songs, uses language fo express roles, verbal reasoning Gross motor: more sedate, good mus cle control and balance, hops on one foot 3 + times, hops in a straight line, bounces and catches ball, skips, somersaults, skates, lifts self off ground interest: in reality— manipulation o f real-life situations, making some thing useful, permanence o f prod ucts, toys that “really work” Manipulation: uses tools to make things, copies, traces, combines ma terials Construction: makes recognizable products, likes small construction, at tends to detail, uses products in play Purpose; replicates reality Attention: plays with single object or theme 15 + min Imitation: continues to construct new themes with emphasis on reality— reconstruction o f real world ' DransafeitioiK sequent*® stories, cos tumes im portant, prop*, puppets, directs actions o f three dolls— mak ing them interact, organizes other children and props for role play Type: cooperative groups o f 3 so 6, o r ganization o f m ore com plex games and dramatic play, competitive games, understands rules o f lair play Cooperation: compromises to facili tate group play, rivalry in competi tive play, games with rules, collabo rative play where roles are coordi nated and themes are goal directed Husnon laughs at multiple meanings of words Language: prominent in sociodram atic play, uses words as part o f play as well as to organize play, interest in present, conversation like adults’ , uses relational terms, sings and dances to reflect meaning o f songs From Play in Occupational Therapy for Children (pp. 47-49), by D. Parham and L. Fazio (Eds.), 1997, St. L o u i s : Mosby. C o p y r i g h t 1 9 9 7 by th e M o s b y / E l s e v i e r . R e p r i n t e d w i t h p e r m i s s i o n . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 237 APPENDIX D PRESCHOOL PLAY SCALE: DATA SHEET C o d e # : _ _______ C h i l d ’s N a m e : D a t e o f B i r t h : D a t e o f O b s e r v a t i o n : T i m e o f O b s e r v a t i o n : P l a c e o f O b s e r v a t i o n : C h r o n o l o g i c a l A g e : G r o u p o f S a m p l e s : I n d o o r , I n d o o r , I n d o o r , y e a r s , m o n t h s . N o r m a l D e v e l o p m e n t A u t i s m _ O u t d o o r , _ _ _ _ _ _ _ _ O u t d o o r , _______________ O u t d o o r , __________ A d d i t i o n a l c o m m e n t s o n b e h a v i o r o b s e r v e d ( i n c l u d e s u c h i n f o r m a t i o n a s a g e n e r a l d e s c r i p t i o n o f t h e b e h a v i o r , l a c k o f a n y d i m e n s i o n s , a n d a n y u n u s u a l b e h a v i o r ) : T h e f o l l o w i n g t o b e f i l l e d a f t e r t h e o b s e r v a t i o n s a r e r e c o r d e d : M e a n a g e s f o r t h e d i m e n s i o n s : S p a c e M a n a g e m e n t : P r e t e n s e / S y m b o l i c : M a t e r i a l M a n a g e m e n t : _________ _ P a r t i c i p a t i o n : P l a y A g e : ( m e a n o f a l l d i m e n s i o n s ) _____________________ _________________________ Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 238 APPENDIX E INTRODUCTORY BROCHURE I - C h in g L e e , a P h .D . c a n d id a te o f th e D e p a r tm e n t o f O c c u p a tio n a l S c ie n c e a n d O c c u p a tio n a l T h e ra p y a t th e U n iv e r s ity o f S o u th e rn C a lifo rn ia , L o s A n g e le s , C a lifo rn ia , U .S .A ., is lo o k in g fo r p a r tic ip a n ts in a re s e a rc h s tu d y . W h a t is th e study about? T h e s tu d y is a b o u t a s s e s s in g n a tu ra l p la y in b o y s w ith a u tis m a n d c o m p a rin g it to th a t o f b o y s w ith o u t d is a b ilitie s , a g e 3 to 5 y e a r s , in T a iw a n . T h e r e s e a rc h e r h o p e s to le a m m o re a b o u t p la y p e r f o r m a n c e o f b o y s w ith a u tis m a n d w ith o u t d is a b ilitie s in th e n a tu ra lis tic e n v iro n m e n t w ith T a iw a n e s e s o c ie ty . W h o can p a r t i c i p a t e ? •Boys without Disabilities T h is te r m r e fe rs to c h ild re n , m a le , 3 to 5 y e a r s o f a g e , w h o h a v e n o t d e m o n s tra te d a n y p s y c h ia tr ic , p s y c h o lo g ic a l, p h y s io lo g ic a l, o r n e u ro lo g ic a l p ro b le m s a s r e p o r te d b y h is p a r e n t w ith s e v e ra l s c r e e n in g q u e s tio n s . F o r e x a m p le , c h ild re n s h o u ld n o t c u rre n tly re c e iv e s p e c ia l th e ra p e u tic s e rv ic e s a n d n o t ta k e re g u la r p r e s c r ip tio n m e d ic a tio n s (e .g ., fo r h y p e ra c tiv ity , s e iz u re s ). •Boys with Autism C h ild re n , m a le , 3 to 5 y e a rs o f a g e w h o h a v e r e c e iv e d a p s y c h ia tr ic d ia g n o s is o f a u tis tic d is o rd e r b a s e d o n th e c rite ria fo r d ia g n o s is s e t fo r th in DSM IV (A P A , 1 9 9 4 ) a n d d ia g n o s e d b y th e s p e c ia l in te rd is c ip lin a ry te a m o f c lin ic ia n s in a n y g e n e r a l h o s p ita ls . W hat w ill participation involve? t I f y o u d e c id e to le t y o u r c h ild p a rtic ip a te in th is s tu d y , y o u w ill b e a s k e d to fill o u t th e d e m o g ra p h ic in fo r m a tio n a b o u t y o u r f a m ily ( it o n ly ta k e s 2 -3 m in u te s to c o m p le te ). • A 1 0 -1 5 m in u te s Chinese Version of Peabody Picture Vocabulary Test-Revised (PPVT-R) w ill b e a d m in is te r e d to th e c h ild to p r o v id e a n e s tim a te o f th e c h ild ’s d e v e lo p m e n ta l a g e e q u iv a le n t. T h e Chinese Version of PPVT-R te s tin g w ill ta k e p la c e in a q u ie t ro o m a t s c h o o l, a t th e n u rs e ry , o r a t th e h o m e o f th e c h ild , d e p e n d in g o n w h a t is m o s t c o n v e n ie n t o r a p p ro p ria te . ® T h e p rin c ip a l in v e s tig a to r w ill th e n a rra n g e th e p la c e s a n d tim e s to o b s e r v e y o u r c h ild in p la y a t y o u r c o n v e n ie n c e . T h e p r in c ip a l in v e s tig a to r w o u ld like to o b s e r v e y o u r c h ild in a fre e p la y s itu a tio n in a f a m ilia r e n v iro n m e n t, i f p o s s ib le , w ith o th e r c h ild re n p re s e n t. A to ta l o f tw o s e s s io n s , o n c e in d o o rs a n d o n c e o u td o o rs , e a c h u p to 4 0 - m in u te s in le n g th is a n tic ip a te d . T h e p r in c ip a l in v e s tig a to r w ill v id e o ta p e s e s s io n s a s u n o b tru s iv e ly a s p o s s ib le to h e lp w ith a n a ly s is o f th e p la y . W hat are the potential r is k s associated w i t h t h e participation? T h is s tu d y is d e s ig n e d to o b s e r v e c h ild re n in fr e e p la y s itu a tio n , in th e n a tu r a lis tic a n d fa m ilia r e n v iro n m e n t, in th e ir o rd in a rily e n c o u n te r e d in d a ily lif e , w ith th e ir s u p e r v is in g a d u lts p r e s e n t, w ith n o m a n ip u la tio n o f v a ria b le s . N o p o te n tia l ris k s a n d d is c o m f o r t a re a n tic ip a te d a s a r e s u lt o f p a r tic ip a tio n . W hat are the potential benefits a s s o c ia t e d w ith t h e p a r t i c i p a t i o n ? T h e c h ild in v o lv e d in th is s tu d y w ill r e c e iv e n o d ir e c t b e n e f its b y p a r tic ip a tin g . H o w e v e r , th e s u b je c t’s p a r e n t w ill b e g iv e n th e te s t r e s u lt (i.e ., th e p e r c e n tile s c o r e o f th e c h ild o n the Chinese Version of PPVT-R in th e a p p ro p ria te a g e g ro u p o f T a iw a n e s e c h ild re n ) th a t in d ic a te s th e c h ild ’s d e v e lo p m e n ta l a g e e q u iv a le n t. I f n e c e s s a ry , th e r e fe rr a l in fo r m a tio n w ill a ls o b e g iv e n to th e p a r e n t f o r fu r th e r d e ta ile d a s s e s s m e n t. H ow w ill this study benefit others? T h e k n o w le d g e g a in e d fr o m th is s tu d y m a y h e lp in u n d e r s ta n d in g th e s ig n ific a n c e o f p la y in c h ild re n w ith o u t d is a b ilitie s a n d in e v a lu a tin g a n d tr e a tin g c h ild r e n w ith a u tis m . IF T H IS S O U N D S I N T E R E S T IN G T O Y O U A N D Y O U W O U L D L I K E T O P A R T I C I P A T E IN T H I S S T U D Y O R H A V E A N Y Q U E S T IO N S R E G A R D I N G T H IS S T U D Y , P L E A S E C O N T A C T : I-CHING LEE A T (07) 370-5989 IN T A IW A N . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 239 INTRODUCTORY BROCHURE (CHINESE VERSION) * . a % $ ,% ■ % & £ } m & m m A « « # • * ? • £ ffl £ J J f £ # : * ;f i&H ^ A i A *> fi t J i * f K S * * f A M t DSM i v ( a p a , ] 994m m m t > a « £ * . m m m * ? • * * w t & « # i i * * itm ft-s t t * . t- » «. s - ■ & * & t * t * *< a * s# 2- 3 ^ it ) ® * ? ? ■ £ ?f t a # a » « »] A # #• & & « ? ■ £ tt j # is t ,« t A *.^ if-tr # g t ! * ] £ » J i 6 S t (Peabody P ic tu r e V o c a b u la r y Test-Revised),i t . f r £-3 + 5 . + i d-J t S #»». jfc«» t f: Aft # # # $ S 3 rn it-fr. & if t £ # a tf n t- & & it t ® sf s j&s, a m % m 4.& # st # m n af & 1 5 , € - , I ft it it ^ J T s .il ^ it * - f t ^ - * ? f t * t t i # A * f ® * it# ^ A m t , & a # * # a,& ^ 2 & # m 1 1 ^ ^ # ± if ^ ^ i£ # . # T A,f- # t if # # t » $•& #& *.*£& **?? *- M * ■ O f£ W * t » & i * tt 6 Ait ii. & m i , i & m - # n m & # lI tt * i? & S 3 #-# £#«,*» tx & f M r e .# # * ! #■ & « , . ^ a # s # i t ■- # i f # J i # IS S B w # # f m. £ m - & m t ^ ^ # # i k £ # # ii M . % # f & f > ¥ ; it * f s * - I - f a i « • s f c > 6 # ■ ^ ,# t ^ # 0 . n m i ^ a a =. a s . m & # A it # # h & % l€ a - £ m ± sd a g lid ilis g a f # tt ^ «4i t # * t« f a a anm. r = u if nvt fin t i# a $ t * (07-3705989)#^. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 240 APPENDIX F SCREENING QUESTIONS FOR CHILD’S NORMALCY: PARENT’S INTERVIEW GUIDE I A M G O I N G T O A S K Y O U S E V E R A L Q U E S T I O N S . T H E S E Q U E S T I O N S W I L L HELP M E T O F I N D O U T I F Y O U R C H I L D I S E L I G I B L E T O B E A P A R T I C I P A N T I N T H I S R E S E A R C H S T U D Y . P L E A S E T A K E T I M E I F Y O U N E E D T O T H I N K A B O U T Y O U R A N S W E R S . F E E L F R E E T O I N T E R R U P T M E A N D A S K A N Y Q U E S T I O N S I F Y O U D O N O T U N D E R S T A N D A N Y P A R T S O F T H E Q U E S T I O N S . C h i l d ’s Name: T o d a y ’s Date: ____________________________________________ W h a t is y o u r r e l a t i o n s h i p t o t h e c h i l d ? ___ F a t h e r M o t h e r 1. C a n y o u p l e a s e t e l l m e a b o u t y o u r c h i l d ’s h e a l t h ? ( e .g . , p h y s i c a l w e l l - b e i n g , m e n t a l w e l l - b e i n g ) 2 . H a v e y o u b e e n t o l d b y a n y p r o f e s s i o n a l s ( e .g . , c l i n i c i a n , p s y c h o l o g i s t , o r t h e r a p i s t ) t h a t t h e c h i l d d e m o n s t r a t e s a n y p r o b l e m s t h a t m a y a f f e c t h i s d a i l y l i v i n g b e h a v i o r s / f u n c t i o n s ? N o . _ _ Y e s . I f y e s , p l e a s e d e s c r i b e : 3 . H a v e a n y p r o f e s s i o n a l s d i a g n o s e d / i n d i c a t e d t h a t t h e c h i l d h a s a n y s y m p t o m s , d i s a b i l i t i e s , o r d i s e a s e s ? N o . _____ Y e s . I f y e s , p l e a s e d e s c r i b e : 4 . D o e s t h e c h i l d c u r r e n t l y r e c e i v e a n y s p e c i a l t h e r a p e u t i c s e r v i c e s ? N o . _____ Y e s . I f y e s , p l e a s e d e s c r i b e : 5 . D o e s t h e c h i l d c u r r e n t l y t a k e r e g u l a r p r e s c r i p t i o n m e d i c a t i o n s ( e .g . , f o r h y p e r a c t i v i t y , s e i z u r e s ) ? N o . _____ Y e s . I f y e s , w h a t i s ( a r e ) t h e m e d i c a t i o n ( s ) f o r ? 6 . I s t h e r e a n y t h i n g e l s e t h a t w a s n o t c o v e r e d i n t h e s e q u e s t i o n s a n d y o u f e e l is a n i m p o r t a n t i s s u e r e g a r d i n g t h e c h i l d t h a t y o u w o u l d l i k e t o s h a r e ? E l i g i b i l i t y C r i t e r i a : ( T h e g u i d e l i n e f o r t h e principal i n v e s t i g a t o r to j u d g e t h e c h i l d ’s n o r m a l c y ) a . C h i l d r e n w h o d e m o n s t r a t e a n y p s y c h i a t r i c , p s y c h o l o g i c a l , p h y s i o l o g i c a l , o r n e u r o l o g i c a l p r o b l e m s w i l l n o t b e r e c r u i t e d . b . C h i l d r e n w i t h s y m p t o m s a s s o c i a t e d w i t h organic b r a i n dysfunction ( e . g . , seizures), o r t h o p e d i c p r o b l e m s , h e a r i n g l o s s , o r g r o s s v i s u a l deficits w i l l b e excluded a s w e l l . c . C h i l d r e n s h o u l d n o t c u r r e n t l y r e c e i v e s p e c i a l t h e r a p e u t i c s e r v i c e s a n d b e n o t t a k i n g a n y r e g u l a r p r e s c r i p t i o n m e d i c a t i o n s ( e .g . , f o r h y p e r a c t i v i t y , s e i z u r e s ) . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. SCREENING QUESTIONS FOR CHILD’S NORMALCY: PARENT’S INTERVIEW GUIDE (CHINESE VERSION) s»*. * * # £ * tjtiaaji; _____ n ____ a ______________ i t f a mM ■■!'&#> M # . : a m . _______-%**, !. if la i t S-' i ■ > fl * A #J A 11A 'O if & «t M A >X: 2 . SAS#Msfe-f-f AiCfclrfe: f * ♦ » f * a f A * # ft I S ! * A A A • ? 5 3. If f l i f J i # # A.4r(fr!*a: f ) A « # t r 5 A-if 4 . U F A « « * « a jw f r t ■ If i&: A . I f MPA®. S I if *,% A? 6 if p f ® -lit if fc a fS f to % ®'b1& * ? Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 242 APPENDIX G INFORMED CONSENT R E S E A R C H P R O P O S A L E N T I T L E D : A C O M P A R I S O N O F P L A Y P E R F O R M A N C E O F B O Y S W I T H A U T I S M A N D B O Y S W I T H O U T D I S A B I L I T I E S I N T A I W A N . P R I N C I P A L I N V E S T I G A T O R : I - C h i n g L e e , P h . D . C a n d i d a t e D e p a r t m e n t o f O c c u p a t i o n a l S c i e n c e a n d O c c u p a t i o n a l T h e r a p y U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a ( 6 2 6 ) 2 8 0 - 5 7 9 3 i n C a l i f o r n i a , U S A 8 8 6 - 7 - 3 7 0 - 5 9 8 9 i n K a o h s i u n g , T a i w a n F A C U L T Y S P O N S O R : D r . M a r y L a w l o r , S c D , O T R , F A O T A U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a 1 5 4 0 A l c a z a r S t r e e t , C H P 1 3 3 L o s A n g e l e s , C a l i f o r n i a 9 0 0 3 3 ( 3 2 3 ) 4 4 2 - 2 8 2 0 P U R P O S E O F T H E S T U D Y Y o u a n d y o u r c h i l d a r e i n v i t e d t o p a r t i c i p a t e i n a s t u d y a s s e s s i n g n a t u r a l p l a y i n b o y s w i t h a u t i s m a n d c o m p a r i n g it t o t h a t o f b o y s w i t h o u t d i s a b i l i t i e s , a g e o f 3 t o 5 y e a r s , i n T a i w a n . T h e p r i n c i p a l i n v e s t i g a t o r h o p e s t o l e a r n m o r e a b o u t p l a y p e r f o r m a n c e o f b o y s w i t h a u t i s m a n d w i t h o u t d i s a b i l i t i e s i n t h e n a t u r a l i s t i c e n v i r o n m e n t w i t h i n T a i w a n e s e s o c i e t y . T h e i n f o r m a t i o n m a y h e l p o c c u p a t i o n a l s c i e n t i s t s a n d o c c u p a t i o n a l t h e r a p i s t s i n t h e u n d e r s t a n d i n g o f t h e d e v e l o p m e n t a l d e f i c i t s t h a t a r e a s s o c i a t e d w i t h a u t i s m a n d t h e i r e f f e c t s o n p l a y , a s w e ll a s i n t h e a s s e s s m e n t a n d t r e a t m e n t o f c h i l d r e n w i t h a u t i s m . I n a d d i t i o n , t h e k n o w l e d g e g a i n e d f r o m t h i s s t u d y m a y a l s o h e l p in t h e u n d e r s t a n d i n g o f th e g e n e r a l s c o p e o f p l a y p e r f o r m a n c e a n d t h e s i g n i f i c a n c e o f p l a y i n c h i l d r e n w i t h o u t d i s a b i l i t i e s w i t h i n T a i w a n e s e s o c i e t y . P R O C E D U R E S O F T H E S T U D Y I f y o u d e c i d e t o l e t y o u r c h i l d p a r t i c i p a t e i n t h i s s t u d y , y o u w i l l b e a s k e d t o f i l l o u t t h e d e m o g r a p h i c i n f o r m a t i o n a b o u t y o u r f a m i l y a n d s i g n t h e i n f o r m e d c o n s e n t . A 1 0 - 1 5 m i n u t e s Chinese Version o f Peabody Picture Vocabulary Test-Revised (PPVT-R) w i l l b e a d m i n i s t e r e d t o t h e c h i l d t o p r o v i d e a n e s t i m a t e o f t h e c h i l d ’s d e v e l o p m e n t a l a g e e q u i v a l e n t . T h e Chinese Version o f PPVT-R t e s t i n g w i l l t a k e p l a c e i n a q u i e t r o o m a t s c h o o l , a t t h e n u r s e r y , o r a t t h e h o m e o f t h e c h i l d , d e p e n d i n g o n w h a t is m o s t c o n v e n i e n t o r a p p r o p r i a t e . T h e d e m o g r a p h i c i n f o r m a t i o n a n d t h e c h i l d ’s p e r f o r m a n c e o n t h e Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 243 Chinese Version o f PPVT-R will be used to assist for clarification, interpretation, and discussion of child’s play. The principal investigator will then arrange the places and tim es to observe your child in play at your convenience. The principal investigator would like to observe your child in a free play situation in a fam iliar environment, if possible, w ith other children present. A total o f two sessions, once indoors and once outdoors, each 40-minutes in length is anticipated. The principal investigator w i l l v i d e o t a p e sessions as u n o b t r u s i v e l y a s possible t o h e l p w i t h analysis o f t h e p l a y . S u b s e q u e n t l y , the v i d e o t a p e s o f c h i l d ’s p e r f o r m a n c e w i l l b e r e v i e w e d b y t h e p r i n c i p a l i n v e s t i g a t o r , a n d t h e c h i l d ’s p l a y p e r f o r m a n c e w i l l b e r e c o r d e d / r a t e d from t h e v i d e o t a p e s o n t h e r a t i n g s c a l e (.Revised Knox Preschool Play Scale). T h e r o l e o f t h e o b s e r v e r ( i .e ., t h e p r i n c i p a l i n v e s t i g a t o r a n d r e s e a r c h a s s i s t a n t s ) w i l l b e t h e n o n - p a r t i c i p a n t a n d w i l l b e f a c i l i t a t e d b y t h e f a c t t h a t t h e r e w i l l b e a l w a y s o t h e r a d u l t s p r e s e n t . T h e o b s e r v e r e x e r t s n o a u t h o r i t y o v e r t h e children. T h e p r i n c i p a l i n v e s t i g a t o r w i l l ask y o u o r a s u p e r v i s i n g a d u l t t h a t y o u d e s i g n a t e t o p l a y w i t h a n d s u p e r v i s e t h e c h i l d i n t h e i r u s u a l m a n n e r a n d t h a t as a n o b s e r v e r , t h e p r i n c i p a l i n v e s t i g a t o r a n d r e s e a r c h a s s i s t a n t s w i l l n o t i n t e r v e n e u n l e s s t h e r e is a p o t e n t i a l l y h a r m f u l s i t u a t i o n ( e .g ., t h e c h i l d is r u n n i n g t o w a r d a m o v i n g v e h i c l e ) . W i t h the r e s p e c t o f t h e n a t u r a l i s t i c s u r r o u n d i n g s i n c h i l d ’s p l a y , y o u o r t h e s u p e r v i s i n g a d u l t w h o p l a y w i t h o r s u p e r v i s e t h e c h i l d i n p l a y s e s s i o n m i g h t a l s o b e v i d e o t a p e d . H o w e v e r , y o u o r t h e s u p e r v i s i n g a d u l t ’s b e h a v i o r s w i l l n o t b e f o c u s e d o r a n a l y z e d . Y o u w i l l b e i n f o r m e d o f a n y c h a n g e s i n t h e n a t u r e o f t h e s t u d y o r i n t h e p r o c e d u r e s described a b o v e . R I S K S : N o r i s k s a r e a n t i c i p a t e d a s a r e s u l t o f p a r t i c i p a t i o n i n t h i s s t u d y . I t is d e s i g n e d t o g a t h e r i n f o r m a t i o n a b o u t t h e c h i l d r e n i n a n a t u r a l f r e e p l a y s i t u a t i o n w i t h n o m a n i p u l a t i o n o f v a r i a b l e s . B E N E F I T S : T h e c h i l d i n v o l v e d i n t h i s s t u d y w i l l r e c e i v e n o d i r e c t b e n e f i t s b y p a r t i c i p a t i n g . H o w e v e r , y o u w i l l b e g i v e n t h e t e s t r e s u l t ( i . e ., t h e p e r c e n t i l e s c o r e o f y o u r c h i l d o n the Chinese Version o f PPVT-R i n th e a p p r o p r i a t e a g e g r o u p o f T a i w a n e s e c h i l d r e n ) t h a t i n d i c a t e s y o u r c h i l d ’s d e v e l o p m e n t a l a g e e q u i v a l e n t . I f n e c e s s a r y , t h e r e f e r r a l i n f o r m a t i o n w i l l a l s o b e g i v e n t o y o u f o r f u r t h e r d e t a i l e d a s s e s s m e n t . The k n o w l e d g e g a i n e d f r o m t h i s s t u d y m ay h e l p i n u n d e r s t a n d i n g t h e s i g n i f i c a n c e o f p l a y i n c h i l d r e n w i t h o u t d i s a b i l i t i e s a n d i n e v a l u a t i n g a n d t r e a t i n g c h i l d r e n w i t h a u t i s m . C O N F I D E N T I A L I T Y : A l l v i d e o t a p e s and any inform ation t h a t i s o b t a i n e d i n c o n n e c t i o n w i t h t h i s s t u d y that c a n b e i d e n t i f i e d to y o u a n d y o u r f a m i l y w i l l r e m a i n s t r i c t l y c o n f i d e n t i a l a n d w i l l be d i s c l o s e d o n l y w i t h y o u r p e r m i s s i o n o r a s r e q u e s t e d b y la w . T h e v i d e o t a p e s o f c h i l d ’s p e r f o r m a n c e w i l l b e r e v i e w e d b y th e p r i n c i p a l i n v e s t i g a t o r , a n d t h e c h i l d ’s p e r f o r m a n c e w i l l b e r e c o r d e d / r a t e d f r o m t h e v i d e o t a p e s o n t h e r a t i n g s c a l e {Revised Knox Preschool Play Scale). W h e n t h e r e s u l t s o f t h e s t u d y a r e p u b l i s h e d o r d i s c u s s e d i n c o n f e r e n c e s , n o i n f o r m a t i o n w i l l b e i n c l u d e d t h a t w o u l d r e v e a l y o u r c h i l d ’s id e n t i t y . O n l y w i t h y o u r c o n s e n t , t h e v i d e o t a p e s m ay b e r e v i e w e d b y m e m b e r s o f t h e p r i n c i p a l i n v e s t i g a t o r ’s d i s s e r t a t i o n c o m m i t t e e f o r c l a r i f i c a t i o n and d i s c u s s i o n o f c h i l d ’s p l a y perform ance a n d b e u s e d f o r e d u c a t i o n a l p u r p o s e s ( e .g . , f o r d e m o n s t r a t i n g c e r t a i n p o i n t s a t p r o f e s s i o n a l m e e t i n g s , f o r p l a y b a c k a t s p e c i a l l e c t u r e s ) . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 244 W ITH DR A W A L A N D A G R E E M E N T Y o u w i l l b e t o l d a n y n e w i n f o r m a t i o n w h i c h m a y a f f e c t y o u r w i l l i n g n e s s t o c o n t i n u e t h i s r e s e a r c h . Y o u r p a r t i c i p a t i o n i n t h i s p r o j e c t is v o l u n t a r y . Y o u m a y w i t h d r a w y o u r c h i l d f r o m t h i s s t u d y a t a n y t i m e w i t h n o n e g a t i v e c o n s e q u e n c e s . Y o u w i l l b e g i v e n a c o p y o f t h i s f o r m t o k e e p . N o w o r later, if a t a n y t i m e y o u f e e l a n y q u e s t i o n s a b o u t t h e r e s e a r c h o r y o u r r i g h t s , y o u m a y c o n t a c t I - C h i n g L e e , t h e p r i n c i p a l i n v e s t i g a t o r , a t ( 0 7 ) 3 7 0 - 5 9 8 9 , i n T a i w a n ; o r D r . M a r y L a w l o r , f a c u l t y s p o n s o r , a t ( 3 2 3 ) 4 4 2 - 2 8 2 0 , i n U .S .A . , f o r a n s w e r s . I f y o u a g r e e t o p a r t i c i p a t e , p l e a s e s i g n i n t h e a p p r o p r i a t e p l a c e b e l o w . C O N S E N T I g i v e m y c o n s e n t to t h e p r i n c i p a l i n v e s t i g a t o r to s h o w t h e v i d e o t a p e s o f m y c h i l d t o t h e m e m b e r s o f t h e p r i n c i p a l i n v e s t i g a t o r ’s d i s s e r t a t i o n c o m m i t t e e f o r c l a r i f i c a t i o n a n d d i s c u s s i o n o f c h i l d ’s p l a y p e r f o r m a n c e . I g i v e m y c o n s e n t t o t h e p r i n c i p a l i n v e s t i g a t o r t o u s e t h e v i d e o t a p e s o f m y c h i l d f o r f u t u r e e d u c a t i o n a l p u r p o s e s ( e .g . , f o r d e m o n s t r a t i n g c e r t a i n p o i n t s a t p r o f e s s i o n a l m e e t i n g , f o r p l a y b a c k a t s p e c i a l le c t u r e s ) . I d e s i g n a t e __________________ ( N a m e ) t o b e t h e s u p e r v i s i n g a d u l t t o p l a y w i t h a n d s u p e r v i s e m y c h i l d t h r o u g h o u t t h e p l a y s e s s i o n s i n t h i s s tu d y . “ I a c k n o w l e d g e t h a t I h a v e f u l l y r e v i e w e d a n d u n d e r s t o o d t h e c o n t e n t s o f t h i s c o n s e n t f o r m . I c o n s e n t t o h a v e m y c h i l d p a r t i c i p a t e i n t h i s r e s e a r c h p r o j e c t . I u n d e r s t a n d t h a t p a r e n t o r l e g a l r e p r e s e n t a t i v e s i g n a t u r e i s r e q u i r e d i n t h i s s t u d y d u e t o t h e a g e 3 t o 5 y e a r s o f t h e c h i l d r e n i n v o l v e d . I u n d e r s t a n d t h a t I m a y r e s c i n d t h i s p e r m i s s i o n a t a n y t i m e w i t h n o n e g a t i v e c o n s e q u e n c e s . I h a v e b e e n g i v e n a c o p y o f th e i n f o r m e d c o n s e n t to k e e p . ” C h i l d ’s N a m e S i g n a t u r e o f p a r e n t o r l e g a l r e p r e s e n t a t i v e R e l a t i o n s h i p t o C h i l d Date “I a g r e e t o b e t h e s u p e r v i s i n g a d u l t t o p l a y w i t h a n d s u p e r v i s e t h e c h i l d J j N a m e ) t h r o u g h o u t t h e p l a y s e s s i o n s i n t h i s study. I understand t h a t I m i g h t b e v i d e o t a p e d d u r i n g t h e p l a y sessions w i t h t h e r e s p e c t o f the n a t u r a l i s t i c s u r r o u n d i n g s i n c h i l d ’s p l a y a n d m y b e h a v i o r s w i l l n o t b e f o c u s e d o r a n a l y z e d . I h a v e b e e n g i v e n a c o p y o f t h e i n f o r m e d c o n s e n t t o k e e p . ” S i g n a t u r e o f s u p e r v i s i n g a d u l t D a t e Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. INFORMED CONSENT (CHINESE VERSION) # ± # 4 a ^mhom- (626)280-5793 (07)370-5989 1 1 -7 -# # ft I I : ichingli@libra.seed.net.tw iching@juno.com Mary Lawlor #-£■ jtrS £ 0 * i « l : (323)442-2820 lawlor@hsc.nsc.edu University of Southern California 1540 Alcazar Street, CHP 133 Los Angeles, California 90033 m%s¥j M f t l t * f Jft.itS* S I til* # # * * •■ # ■ * AiHt* U f 4 # 5 S « A i itsETi a f # t # i± . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 246 - t ' J ' - S n t t !i,lf lut 1 * # • * m 1 1 . ** * tt t ± * Assist m t « a t ,« t aj& a f# 8 1 (Peabody Picture Vocabulary T e s t-R e v is e d ),i t f t & + 5 . + f f # 4 #W tfri-4. * a# to* t 4 *tt t ±# A S f H &« til# § i j a $ S J ,*,», a m &a t • & # si# F t ft sf & ,f., M m ® -ft %«,^r S . & d J #^ ^.(Revised Knox Preschool Play S c a le )# )^ 4 ^ j-ff * * Mwft. m * « * * * $ & a j » sits ***###*,3. a i s m j i m * * WAl.%. m A& m $s& & & « , » J F it)f A,^?gtf i ±# (#!*»: S * A : i . % i f t A S) t i ± » ; 4 * r A If #& * 4S t & & , i & W ft i£i! ,# f M .«. ih ti I ft if*.# A .* ■ « f 5 £ it A #Aft to * A & m ; s®.fk- » m «,*■ + a®, fttr a # «#. a t «i * ± ,m m w ^r f e ^ ^ ; i t i f i j =f S* * f A + ^ s l & j & ^ i S ^ I S ^ i S # ^ £ * A # , A t a t f i t VJ ft A m i t .Ff i t A i A i i & , * im ^ -% -3 L .k m t A iS S fctf &*3Ut A- ^sifT-gMti: ; f i& s a t ^ a f i j# i f « r i . % * 6 i i i *-i±. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 247 m a % m 4/k®f&tf t ± # a # ta,sL m * fr$T&nte.&® ®&*.TMtitimM®zLtB m « ®±, «t #!.,«« t*s>f,##,# A , $ i f , 07-370-5989,4 « f % t f i f§ f t f c ^ D r . Mary Lawlor, 323-442-2820.^ ^ n t- a - A & f t 4'« # - & * ■ * * % ,tt^T t T * * 4 . , a j . , s □ * 11 s t « # * J ^ « . # u f * • * r 4 t* f £tf t $ & # «it ■ - # * *,« « f * * ; t M & , * t t tk m t f t A * «.. □ a ^ -t -s.* m t s tt t s & ± m * » :-* • t t - n u * df±) fj ____________!*L^) «-ibSfrt,t f s tsts.»j. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 248 H t t ( j j i i ) Zf t t e s a lii.iL Z fr ik tf c t f-H PO t f t & a n t ft -fr**-= . £ i a # a # ^ m % . n e,« i - © • < » ) & %tf t #- # 3 t - t ” «■£ a tt “ I I F O f . * t « f S t £*« 4_ _ _ . _ _ _ _ _ _ _ ( i d - g H « t 2 |3 S J l % . • • • r % & Si fei^ ^ 3$ 85 s* fj.« ^ | t ^ « a ® Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 249 APPENDIX H DEMOGRAPHIC INFORMATION P L E A S E R E A D AND ANSW ER T H E I N F O R M A T I O N R E Q U E S T E D I N T H I S F O R M . Y O U ARE A S S U R E D T H A T T H E I N F O R M A T I O N T H A T Y O U P U T I N T H I S F O R M W I L L B E T R E A T E D C O M P L E T E L Y C O N F I D E N T I A L AND N O N E O F I T W I L L B E R E L E A S E D I N A N Y W A Y T H A T W O U L D P E R M I T I D E N T I F I C A T I O N O F T H E C H I L D O R Y O U R F A M I L Y . Y O U R I N P U T I S V E R Y M U C H A P P R E C I A T E D . P l e a s e w r i t e d o w n t h e c h i l d ’s n a m e : __________________________ T o d a y ’s D a t e : __________________ P l e a s e w r i t e d o w n t h e c h i l d ’s d a t e o f b i r t h : __________________________ P l e a s e w r i t e d o w n y o u r c u r r e n t a d d r e s s : P l e a s e w r i t e d o w n t h e p h o n e n u m b e r a n d p r e f e r r e d t i m e t h a t y o u c a n b e r e a c h e d : 1. W h a t is y o u r r e l a t i o n s h i p to t h e c h i l d ? _______ F a t h e r M o t h e r 2 . H o w m a n y c h i l d r e n y o u h a v e i n t h e f a m i l y ? 3 . I f y o u d o n ’t m i n d t e l l i n g m e , w h a t is y o u r f a m i l y m o n t h l y i n c o m e ? _ L e s s t h a n N T $ 1 0 ,0 0 0 _ _ N T $ 1 0 , 0 0 0 - 3 0 , 0 0 0 _ _ N T $ 3 0 0 0 0 ~ 5 0 0 0 0 _ N T S 5 0 , 0 0 0 ~ 8 0 , 0 0 0 _ N T S 8 0 , 0 0 0 ~ 1 0 0 , 0 0 0 _ M o r e t h a n N T S 1 0 0 , 0 0 0 4 . W h a t i s t h e m a j o r v o c a t i o n o f t h e c h i l d ’s p a r e n t s ? F a t h e r ________ _ M o t h e r _______________________ 5 . W h a t is t h e h i g h e s t a c a d e m i c d e g r e e t h a t t h e c h i l d ’s p a r e n t s h a v e c o m p l e t e d ? F a t h e r ___________ ___________ M o t h e r ________________________ 6 . W h o is t h e p r i m a r y c a r e g i v e r o f t h e c h i l d ? W e e k d a y : D a y t i m e _______________ N i g h t t i m e _______________ W e e k e n d / H o l i d a y : D a y t i m e _______________ N i g h t t i m e _______________ 7 . W h e r e d o e s t h e c h i l d u s u a l l y s t a y ? W e e k d a y : D a y t i m e ____________ N i g h t t i m e _________ W e e k e n d / H o l i d a y : D a y t i m e N i g h t t i m e _ _ _ _ _ _ _ 8. H a s t h e c h i l d r e c e i v e d a n y special t h e r a p e u t i c o r m e d i c a l services? _ N o Y e s . I f y e s , p l e a s e d e s c r i b e : a n d i f y e s , h o w o l d w a s t h e c h i l d w h e n h e started r e c e i v i n g t h e services? T H A N K Y O U F O R Y O U R P A R T I C I P A T I O N . P L E A S E F E E L F R E E T O W R I T E A N Y A D D I T I O N A L C O M M E N T S O R A N Y T H I N G E L S E T H A T Y O U W O U L D LIK E T O SHARE. T H A N K Y O U A G A I N F O R Y O U R T I M E A N D E F F O R T . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 250 DEMOCSAFH1C INFORMATION (CHINESE VERSION) A ss^-T n n m . a , « a . * # » * « . * * * * * * * f * * * « . « 8 « ; * _____^ ______3 '}'?$%.£:_____________________ 'I'SiiiiS®: • ¥ - _ _ _ _ _i?_____ a '!<«+#: *._____ M tit& sm »■ & .& : » * * m t * ■ « ? » m si. - ! . *4 * f t J t ' M C t t H A : _ _ _ _ _&«._ _ _ 2. Jf 54 *-£.51 ■ * " -fc S * A H 4 t -V7 ___________ A . ii-'K m t i # 10,000 i t *r & f 10,000-30,000 .it m & * 3 0 . 0 0 0 - 5 0 ,0 0 0 i t ~ ____H r # * 50,900-80,000 i t # r # $ ■ 8 0 .0 0 0 - 1 (5 0 ,0 0 0 i t _ _ £ 100,000 i t 4. * * * * & & * * * # * & __________________ 5 . * * * * « £ « * * * : _____ ________________ * * * ']> « -* * * * * : _ 6. jf ? « i it -t i t .•!>«* a s r *? (is - m % s s* - # ■ n a «441 a > 11.— 3fc,_t SIA/S I S 3 ' # A ________________it-t- 7- H 5 4 i t f 13. — a A ________________ 3^,_L ii A/ a AlS 3 : £ t A ___________ 3 ti 8 . * * it * « £ ? # *« 4 * # * & # « V A # ? 4. its! it-MS & £ *.s*. ft_ _ a if if !»m& ■ * * ■ ! & 1 *r? & * * * * £ . Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Lee, I-Ching
(author)
Core Title
A comparison of the play performance of boys with autism and that of boys without disabilities in Taiwan
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Graduate School
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Doctor of Philosophy
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Occupational Science
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University of Southern California
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education, special,health sciences, rehabilitation and therapy,OAI-PMH Harvest,psychology, developmental
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English
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Lawlor, Mary (
committee chair
), Mack, Wendy (
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), Neville-Jan, Ann (
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committee member
), Turman, Jack (
committee member
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Lee, I-Ching
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education, special
health sciences, rehabilitation and therapy
psychology, developmental