Play-based occupational therapy intervention on social skills in children with autism spectrum disorder and attention deficit hyperactivity disorder: A case series

Kinkuri Sahib Kaur; Ranjit Pathak

doi:10.4103/ijoth.ijoth_5_19

CASE REPORT

Year : 2019 | Volume : 51 | Issue : 1 | Page : 31-36

Play-based occupational therapy intervention on social skills in children with autism spectrum disorder and attention deficit hyperactivity disorder: A case series

Kinkuri Sahib Kaur¹, Ranjit Pathak²
¹ Department of Occupational Therapy, Inspiration the Learning Centre, New Delhi, India
² Department of Occupational Therapy, IAHSET, Government Medical College, Haldwani, Uttarakhand, India

Date of Submission	01-Mar-2019
Date of Acceptance	05-Mar-2019
Date of Web Publication	19-Apr-2019

Correspondence Address:
Dr. Kinkuri Sahib Kaur
H-379, Jalvayu Vihar, Sector 30, Gurgaon - 122 001, Haryana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijoth.ijoth_5_19

Abstract

The profound deficit in social reciprocity skills is the core underlying feature of the autism spectrum disorder. Inattention and impulsivity of attention deficit hyperactivity disorder children interferes with their ability to accurately identify, imitate, and model appropriate social behaviors. Social skill is any skill that facilitates interaction and communication with others, and evidence suggests that they can be acquired with specific training, opportunities, and practices. Literature suggests that in a developmental approach to social skills training, play is used as the primary medium for intervention, especially with younger children. Three children in the age group of 4–5 years were selected for the study. Socialization domain of the Vineland adaptive behavior scales-second edition was used to get the baseline scores. The children participated in the play-based occupational therapy intervention and each session was carried out for 60 min, twice a week. The children were reassessed after 6 months. The scores' data showed an upward trend and the socialization score of child 1, 2, and 3 improved by 11.6%, 14.8%, and 8.3%, respectively.

Keywords: Attention Deficit Hyperactivity Disorder, Autism, Intervention, Play, Social Skills

How to cite this article:
Kaur KS, Pathak R. Play-based occupational therapy intervention on social skills in children with autism spectrum disorder and attention deficit hyperactivity disorder: A case series. Indian J Occup Ther 2019;51:31-6

How to cite this URL:
Kaur KS, Pathak R. Play-based occupational therapy intervention on social skills in children with autism spectrum disorder and attention deficit hyperactivity disorder: A case series. Indian J Occup Ther [serial online] 2019 [cited 2023 Mar 31];51:31-6. Available from: http://www.ijotonweb.org/text.asp?2019/51/1/31/256603

Introduction

Autism spectrum disorder (ASD) is characterized by deficits in social communication and social interaction across multiple contexts. They face challenges with social engagement and age-appropriate play and fail to develop appropriate peer relationships according to their developmental level.^[1] Children with attention deficit hyperactivity disorder (ADHD) have significant problems with executive functions.^[2] They display deficient social skills that may lead to disturbed interactions and social rejection.

Social skills may be defined as socially acceptable learned behaviors that enable person to interact with others in ways that elicit positive responses and assist in avoiding negative responses.^[3] In the past 10–15 years, social skills interventions have become increasingly sophisticated, including play, perspective taking, and conversation skills.^[4] There is no denying that play is fun, and certainly fun is its biggest draw for children. However, as children play, they also develop critical cognitive, emotional, social, and physical skills.^[5] Play therapy helps children learn new social skills and relational skills with family.^[6] Peer strategies are used as a vehicle for increasing learning and improving social relationships of students with autism and other developmental disabilities.^[7] Play therapy acts as an effective way for learning, developing and enhancing social skills and play is used as the primary medium for intervention, especially with younger children.^[8] Interventions designed to improve social difficulties have demonstrated minimal effectiveness. Thus, there is a clear need to establish interventions that are effective in addressing the social difficulties of children with ASD and ADHD.

Patient Information

Child 1 was 5 years and 6 months-old-boy diagnosed with ADHD, studying in Grade 1. He was the second born child and born from a nonconsanguineous marriage. He was born at term gestation with normal birth weight. No significant antenatal and postnatal complications were reported. Developmentally he started sitting without support by 8 months and walking independently by 1 year.

Child 2 was 4 years and 5 months-old-boy diagnosed with ADHD, studying in nursery class. He was the only child and born from a nonconsanguineous marriage. He was born at full term by cesarean delivery. He cried immediately after birth. No significant antenatal and postnatal history was reported. Developmentally, he started sitting without support by 8 months and was walking independently by 16 months. He had mild language delay, and speech still lacks clarity.

Child 3 was 5 years and 5 months-old-boy diagnosed with ASD, studying in Grade 1. He was the second born child, born from a nonconsanguineous marriage. He was born at full term by normal delivery. No significant antenatal and postnatal history was noted. However, he had a history of neonatal jaundice and was given phototherapy for it. Early developmental milestones have been normal for age with language delays.

Clinical Findings

Clinical findings of the three children are summarized in [Table 1].

Table 1: Clinical Findings

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Timeline

The study was conducted between May 2014 and November 2014 at the Inspiration Centre, New Delhi. Written informed consent was taken from the parents before the study initiation.

On day 1, baseline scores of Vineland Adaptive Behavior Scales-Second Edition (VABS-II)^[9] were taken of all the three children and then 24 weeks intervention protocol was administered. On the last day, scores were reassessed. The study flowchart is shown in [Figure 1].

Figure 1: Study Flowchart

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Assessment

VABS-II was used as a preintervention and postintervention measure. The test is designed to measure adaptive behavior of individuals from birth to age 90. In this study, only socialization domain was used.

It included:

Interpersonal Relationships: How the individual interacts with others
Play and Leisure Time: How the individual plays and uses leisure time
Coping skills: How the individual demonstrates responsibility and sensitivity to others.

The baseline scores are summarized in [Figure 2].

Figure 2: Pre and Postintervention Scores of the Three Children

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Intervention

Play-based intervention sessions were carried out for 60 min, twice a week for 24 weeks. One parent per child was present during the assessments and one parent per child in rotation per session participated in the group intervention sessions. This was done for gaining trust and compliance of parents for the child's therapy sessions. The focus in the sessions was on the symbolic play, pretend play, rule-based play and role play. Various social skills such as greetings, turn-taking, sharing materials, helping others, asking permission, encouraging others, asking for help, apologizing, waiting patiently, listening actively, following rules, and initiating a conversation were practiced using play as a medium. Star chart, token economy, and balloons were used to reinforce the learning skill and correct behavior. The sessions were videotaped, and debriefing of the session was done after every session and it was documented. The 60 min session was divided into four parts. [Table 2] and [Figure 3] show the summary of intervention session.

Table 2: Play Based Intervention

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Figure 3: Play-Based Intervention

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Follow-Up and Outcomes

After intervention, all the three children showed improvement in all the three subdomains. The scores' data showed an upward trend and the socialization score of child 1, 2, and 3 improved by 11.6%, 14.8%, and 8.3%, respectively.

The outcomes are summarized in [Figure 2].

Discussion

The purpose of this study was to see the effect of play-based occupational therapy (OT) intervention on social skills on three children diagnosed with ASD and ADHD. Their Preintervention and Postintervention scores of socialization domain and its subcomponents (interpersonal, play and leisure, and coping skills) were compared using VABS-II.

Improvement in all the three subdomains of the socialization domain was recorded. This result is supported by Barry et al., which reported that greeting and play skills were improved with the use of structured play sessions; however, less clear improvement was seen in conversation skills.^[10] Hurley-Geffner mentioned that much clear research exits on the benefits of friendships in relation to the facilitation of social development.^[11] A meta-analysis conducted by Bratton, et al. of 93 controlled outcome studies too showed strong effectiveness of play-based interventions for changing behavior and improving social adjustments^[12] and Stichter et al. reported that children age 11–14 with high functioning autism or Asperger syndrome showed significant improvement in social skills using cognitive behavioral principles.^[13] Similarly, The National Association for the Education of Young Children in a 2009 position paper described the play as an “important vehicle for developing self-regulation as well as for promoting language, cognition, and social competence.”^[14] They describe how research shows links between play and foundational capacities such as memory, self-regulation, oral language abilities, social skills, and success in school. Data collected on students with autism using peer buddy approach by Laushey and Heflin also indicated that there was a significant increase in appropriate social interactions.^[15] Another study by Legoff and Sherman, showed significant improvement in the communication and socialization domains of the VABS using LEGO play and the no-intervention control group did not improve significantly.^[16] Furthermore, Baggerly and Parker (2005) also suggested that play therapy acts as an effective way for learning, developing, and enhancing social skills and reducing anxiety. However, Ozonoff and Miller showed no improvement in social competence in autism by giving social skill training^[17] and small-to-moderate improvement was shown by Cotter^[18] and Provencal.^[19]

The interpersonal relationship subdomain scores of the children demonstrated improvement, supported by La Greca and Santogrossi, as their study demonstrated increased skill in a role-play situation, a greater verbal knowledge of how to interact with peers, and more initiation of peer interactions in school.^[20] Interventions based on principles of applied behavior analysis have been shown to improve functional communication skills in children with ASD and decrease problematic behaviors such as aggression.^[21] However teacher-report data from a multi-component social skills intervention by Beaumont and Sofronoff, suggested that there was no difference in the improvements made by children in the intervention and control conditions on facial expression, and body-posture recognition measures^[22] and Barry et al. said that despite specific instruction, however, improvement in conversation skills showed smaller effects.^[10] This difference in improvement across skills may indicate that some skills are more amenable for teaching using scripts and concrete rules, while perhaps “higher level” skills (e.g., maintaining a conversation) require different teaching approaches.

The play and leisure subdomain scores of the children demonstrated improvement. A study by Barry et al. supported the result and found that play skills and greeting skills (based on coded observations) improved when they were specifically taught.^[10]

The coping skills subdomain scores of the children demonstrated improvement. Teacher-report data from a multi-component social skills intervention by Beaumont and Sofronoff supported this and confirmed that treatment group participants were able to suggest better appropriate emotion-management strategies for story characters at postintervention than at preintervention, whereas control participants were not.^[22]

Limitation

The following limitations are found in the study:

Participants were selected from only one institution with narrow age range; hence, the result cannot be generalized
As the scores of the subjects were dependent on parental perception about the child, parental bias may have affected the scores
Follow-up to see the long-term effects of play based intervention were not conducted.

Recommendations for the Future Research

A replication of this study on a large sample to enhance the validity of the study
As this study was a case series design and subjects were taken from one institution, future studies with other designs and different institutions (rural-urban) can be done for generalization of results
A longitudinal study should be done to see the effect of play-based intervention on the social skills of ASD and ADHD children.

Conclusion

We studied the effects of play-based OT intervention on the social skills of children with ASD and ADHD. The findings of the study demonstrate that the play-based OT intervention has an effect on the social skills of children with ASD and ADHD. The scores' data showed an upward trend from pre- to postintervention in all the three children. The interpersonal relationship score of Child 1, 2, and 3 improved by 8.7%, 10.5%, and 5%, respectively. The play and leisure time score of Child 1, 2, and 3 improved by 7.5%, 8.8%, and 7.5%, respectively. The coping skills score of Child 1, 2, and 3 improved by 18.8%, 25%, and 12.5%, respectively.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate parent's consent forms. In the form the parents have given their consent for their child's images and other clinical information to be reported in the journal. The parents understand that their child's names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. The study was conducted adhering to the principles of Declaration of Helsinki.

Acknowledgment

We would like to thank the Director of Inspiration the learning centre, New Delhi for the permission and support to conduct the study. We would also like to thank Dr. Ebenezer Wilson Rajkumar D., Dr. Amitabh K. Dwivedi, Dr. Santosh Kumar and Dr. Santosh Shintre for their guidance and teachings. Last but not the least the parents, who willingly enrolled their children for the study and rendered corporation in promptly attending the intervention sessions and throughout the course of data collection.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

References

1.	Luciano, Kristy MS, PA-C. Autism spectrum disorder. J Am Acad PAs 2016;29:14-15.
2.	Kooij SJ, Bejerot S, Blackwell A, Caci H, Casas-Brugué M, Carpentier PJ, et al. European consensus statement on diagnosis and treatment of adult ADHD: The European network adult ADHD. BMC Psychiatry 2010;10:67.
3.	Gresham FM, Elliott SN. Assessment and classification of children's social skills: A review of methods and issues. Sch Psychol Rev 1984;13:292-301.
4.	Sasso GM, Hughes GG, Swanson HL, Nov ak CG. A comparison of peer initiation interventions in promoting multiple peer initiators. Educ Train Ment Retard 1987;22:150-155.
5.	White RE. The Power of Play: A Research Summary on Play and Learning; 2012. p. 1-32. Available from: https://www.childrensmuseums.org/images/MCMResearchSummary.pdf. [Last accessed on 2018 Aug 10].
6.	Abramsandassociates.com. (n.d.). Play Therapy Makes a Difference. [online] Available from: http://abramsandassociates.com/wp-content/uploads/Play-Therapy-Makes-a-Difference-handout.pdf. [Last accessed on 2018 Jul 05].
7.	Kamps D, Locke P, Delquadri J, Hall RV. Increasing academic skills of students with autism using fifth grade peers as tutors. Educ Treat Child 1989;12:38-51.
8.	Counsellingconnection.com. Developing Social Skills with Play Therapy \| Counselling Connection; 2010. [online] Available at: https://www.counsellingconnection.com/index.php/2010/09/30/developing-social-skills-with-play-therapy/. [Last accessed on 2018 Jul 05].
9.	Sparrow SS, Cicchetti DV, Balla DA. Vineland-II Adaptive Behaviour Scales: Survey Forms Manual. Circle Pines, MN: AGS Publishing; 2005.
10.	Barry TD, Klinger LG, Lee JM, Palardy N, Gilmore T, Bodin SD. Examining the effectiveness of an outpatient clinic-based social skills group for high-functioning children with autism. J Autism Dev Disord 2003;33:685-701.
11.	Hurley-Gefner CM. Friendships between children with and without disabilities. In: Koegel RL, Koegel LK, editors. Teaching Children with Autism: Strategies for Initiating Positive Interactions and Improving Learning Opportunities. Baltimore: Brookes; 1995. p. 127-146.
12.	Bratton S, Ray D, Rhine T, Jones L. the efficacy of play therapy with children: A meta – Analytic review of treatment outcomes. Prof Psychol 2005;36:376-390.
13.	Stichter JP, Herzog MJ, Visovsky K, Schmidt C, Randolph J, Schultz T, et al. Social competence intervention for youth with Asperger syndrome and high-functioning autism: An initial investigation. J Autism Dev Disord 2010;40:1067-1079.
14.	Naeyc.org. National Association for Education of Young Children. NAEYC Position Statement: Developmentally Appropriate Practice in Early Childhood Programs Serving 7 Children from Birth through Age 8;2009. [online] Available at: http://www.naeyc.org/fi les/naeyc/file/positions/PSDAP.pdf. [Last accessed on 2016 Jul 19].
15.	Laushey KM, Heflin LJ. Enhancing social skills of kindergarten children with autism through the training of multiple peers as tutors. J Autism Dev Disord 2000;30:183-193.
16.	Legoff DB, Sherman M. Long-term outcome of social skills intervention based on interactive LEGO play. Autism 2006;10:317-329.
17.	Ozonoff S, Miller JN. Teaching theory of mind: A new approach to social skills training for individuals with autism. J Autism Dev Disord 1995;25:415-433.
18.	Cotter MW. Improving the Social Behaviour of High Functioning Children with Autism: A Social Skills Support Group Intervention. Unpublished Doctoral Dissertation, University of Alabama; 1997.
19.	Provencal SL. The Efficacy of a Social Skills Training Program for Adolescents with Autism Spectrum Disorders. Unpublished Doctoral Dissertation, University of Utah; 2003.
20.	La Greca AM, Santogrossi DA. Social skills training with elementary school students: A behavioral group approach. J Consult Clin Psychol 1980;48:220-227.
21.	Hanley GP, Iwata BA, Thompson RH. Reinforcement schedule thinning following treatment with functional communication training. J Appl Behav Anal 2001;34:17-38.
22.	Beaumont R, Sofronoff K. A multi-component social skills intervention for children with Asperger syndrome: The junior detective training program. J Child Psychol Psychiatry 2008;49:743-753.