The Indian Journal of Occupational Therapy

: 2019  |  Volume : 51  |  Issue : 3  |  Page : 96--101

Pretend play as a therapeutic modality to enhance social competence in children with autism spectrum disorder:A quasi-experimental study

N Rhema Anu1, S Sugi2, K Rajendran3,  
1 Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
2 KMCH College of Occupational Therapy, Coimbatore, Tamil Nadu, India
3 KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India

Correspondence Address:
Dr. N Rhema Anu
Occupational Therapist, Department of Occupational Therapy, Kovai Medical Center and Hospital, Coimbatore - 641 014, Tamil Nadu


Background: Social development for a child is the child's ability to approach others, get along with other children and their ability to manage a relationship with other peers. Play as an occupation allows the child to express who they are as a player and to socially interact with others. Such a recognized play for a child to develop important skills is pretend play. Children who do not imitate or initiate play are likely to have difficulty in some area of childhood performance that limits their ability to respond. Objectives: To explore the pretend play behaviors and to improve social competence through pretend play for children with autism spectrum disorder (ASD). Study Design: A prospective, comparative, interventional, quasi-experimental study design was chosen for this research. Methods: The study included 42 children, aged 3–7 years of both genders, diagnosed with ASD, verbalizing a word or two productively for interacting. All the children were assessed using Child-Initiated Pretend Play Assessment and Communication DEALL Developmental Checklist for social skills, who were then grouped into experimental group with Learn to Play program and into control group who were under general play-based social skill training for 80–100 sessions within 6 months of the study period. Results: Nineteen children out of 21 in the experimental group showed the presence of typical indicators of pretend play. There was a significant improvement (P < 0.005, 95% confidence interval [CI]: 0.000–0.069) in pretend play skills and social skills of the children in the experimental group after Learn to Play program. Further, an improvement on the elaborate play and imitative actions of pretend play and social skills of the control group (n = 21) was attained by general play-based social skill training. However, the effect of pretend play in the experimental group (P < 0.005, 95% CI: 0.000–0.133) was more than that in the control group. Conclusion: Learn to Play program to develop and improve pretend play of children with ASD is better than the general play-based social skill training. The study thus concludes that pretend play is an efficacious therapeutic modality to enhance social competence of children with ASD.

How to cite this article:
Anu N R, Sugi S, Rajendran K. Pretend play as a therapeutic modality to enhance social competence in children with autism spectrum disorder:A quasi-experimental study.Indian J Occup Ther 2019;51:96-101

How to cite this URL:
Anu N R, Sugi S, Rajendran K. Pretend play as a therapeutic modality to enhance social competence in children with autism spectrum disorder:A quasi-experimental study. Indian J Occup Ther [serial online] 2019 [cited 2022 Aug 19 ];51:96-101
Available from:

Full Text


Social competence is defined as “behaviors and cognitions that reflect successful social functioning with peers. The socially competent child is effective in meeting his or her social goals with peers, yet flexible and sensitive in responding to social communications from peers.”[1]

Children with autism spectrum disorder (ASD) often experience challenges surrounding social pragmatics, emotion regulation, expression, and understanding. These deficits may possibly lead to rejection and isolation from peers.[2]

Occupational therapist, focusing on a child, with main role of child as a player, must address for acquisition of play and social skills by providing multiple opportunities for children to engage in pretend play. This improves the children's use of imagination, imitation, and symbolization during their play time. Children participate in group play, interact with others, and increase their social awareness to the children to where they belong and thus promoting their skill development.[2]

Among the studies done previously, a wide age group of children[3] diagnosed with various developmental disabilities were included with fewer ASD children[3],[4],[5] who underwent intervention for pretend play for 6 months with intervention provided twice a week, which may not be adequate for skill acquisition.[6],[7] A presenting limitation of using fewer symbolic play scenarios to improve social competence has also been noted.[8]

This study thus was needed to be done by including a larger sample of children with ASD including children within the age group of 3–7 years, giving therapy frequently in a 6-month time frame, and also by including different levels of social participation in pretend play and symbolic play scenarios to improve the social competence of children with autism and to find the efficacy of the pretend play intervention improving social skills.


The study was conducted in a hospital outpatient area. A prospective, comparative, interventional, quasi-experimental study design was chosen for this research. Moreover, the sample size was determined by the previously done studies.[2],[9] From a sample of 42, odds were recruited in the experimental group and evens were recruited in the control group.

Thus, the study involved an experimental group (n = 21) and a control group (n = 21) of children with ASD[10] of both genders within the age group of 3–7 years with a mean age of 4.3 years (standard deviation [SD] ± 1.36) who can verbalize a word or two to interact productively and the verbalization being clear/unclear. Children who met the criteria of receiving z-score (<−2 and − 1) a level below the average, respectively, in the Child-initiated Pretend Play Assessment (ChIPPA) were included. Children with comorbid physical dysfunctions (such as vision impairment, hearing impairment, and physical disabilities) and those who had difficulty in attending everyday therapy were excluded.

Outcome Measures

The following scales were used to screen the children for inclusion and to measure the pre- and post-treatment effect.


It is a scale used to assess the pretend play of children. It is aimed to assess the self-initiated pretend play of a child. Two areas are focused on the scale as conventional imaginative play and symbolic play with a scoring done for 3-year olds and 4–7-year olds separately.

For 3-year olds, the ChIPPA is divided into play 2 sessions with 9 min assessing conventional-imaginative play and 9 min examining symbolic play.

For 4-year-old to 7-year 11-month-old children, the 30-min session is divided into 2 × 15 min sessions, with one 15 min session being assessment of conventional-imaginative play using the toys while another 15 min session being assessment of symbolic play using the unstructured play materials (Children who are competent players can play for longer than 30 min, but most children are ready to finish at 30 min).

The ChIPPA normative scores are based on z-scores.

These scores are categorized across four levels of performance. These are as follows:

Good performance (above the range of scores >+1)Performance expected for age (within the range, that is − 1 to + 1)Delay for age (that is, scores between − 1 and − 2)Significant delay (scores below − 2 which indicate intervention is needed).

The Percentage of Elaborate Pretend Play Action (PEPA), which shows the child's ability to organize play actions logically and in sequenceThe number of object substitutions (NOS), which indicates the child's capacity to use an object and pretend that it is something elseThe number of imitated actions (NIA), which indicates whether the child has difficulty initiating play ideas and imitates the examiners modeled play actions, are scored.[3]

Communication Deall Developmental Checklist (CDDC)[11],[12],[13]

It is criterion-referenced checklists where the areas of child development are listed. There are 36 items for each domain of development starting from 0–6 to 66–72 months.

The children are scored on a five-point rating to either the skill being not acquired or to completely acquired on the domains of receptive language (RL), expressive language (EL), and social skills.

Symbolic and imaginative play developmental checklist (SIPDC)[14]

This is a checklist consisting of the developmental charts which are referenced for the developmental levels of the play skills being observed in the child. The child was observed in the areas of pre-imaginative play skills and imaginative play skills before the treatment program; after 6 months of intervention, the child was again observed on these areas to find out the advanced play skill levels; postintervention, the ages given in the checklist are regarded as representing average or typical development.


An approval from the ethical committee, permission from the institutional head, and written informed consent from the parents were attained. The samples were screened using the ChIPPA and CDDC before the assessment and grouping process. The children fulfilling the criteria were randomly assigned odd-numbered samples into an experimental group and even-numbered samples in a control group.

The experimental group underwent regular occupational therapy session of 1 h in which pretend play was given for 30 min individually as well as in groups among these children for 6 days in a week covering 80–100 sessions within 6 months. The control group underwent regular occupational therapy session for 1 h in which general play-based social skill training was given for 30 min individually as well as in groups among these children for 6 days in a week covering 80–100 sessions within 6 months.

Both the groups were involved in individual therapy for 60–75 sessions and group sessions with group participatory games for 20–25 sessions during the intervention period. After the completion of therapy for 80–100 sessions, both the experimental group and the control group are assessed using the ChIPPA, CDDC, and SIPDC to evaluate the pretend play, social skills, and developmental skill levels presented postintervention.


Learn to Play

The “Learn to Play program” is used for the development of pretend play.[14] Six skills are the focus of the program. These are sequences of play actions, object substitutions, play scripts (the stories in the play), doll/teddy play, social interaction, and role play. The child was taught imitation of one sequence of play action which is done for 3 days followed by increasing the number of play action sequences with a variety of play materials every 3 days to play individually and slowly introducing to a parallel level of play and so on till the completion of intervention.

Conventional play for the children in control group included use of toys and play materials in which children were given opportunity to choose their own play materials to play, play along with peers in parallel level, and interact with them during play.[15],[16],[17]

Data Analysis

Statistical analysis for this study was done using SPSS version 20 (IBM Corp., Released 2011. Armonk, NY). Descriptive analyses were performed to characterize groups and inferential analyses to compare performance between the groups was computed with Mann–Whitney U and Wilcoxon signed-rank test with setting a confidence level at α ≤ 0.05 and 95% confidence interval (CI).


The age of the selected subjects ranged from 3 to 7 years with 16 boys and 5 girls in the experimental group (mean age 3.9 years) and 19 boys and 2 girls in the control group (mean age 4.8 years) as shown in [Table 1].{Table 1}

The components of pretend play – Percentage of Elaborate Actions (PEPA), NOS, and NIA – and the components of social skills – RL, EL, language (Lang – total score), and social skills – were analyzed in the statistics [Table 2]. The pretest scores of experimental and control groups for the components of pretend play and social skills were analyzed using Mann–Whitney test which showed the homogeneity of the groups (P < 0.005). The posttest scores of the experimental group and control group showed a significant difference (P < 0.005), explaining a difference postintervention. The pretest and posttest scores of individual groups were analyzed using Wilcoxon signed-rank test, which showed a significant difference. With higher positive ranks in the experimental group explaining, the experimental group improved post pretend play intervention in the components of pretend play – PEPA (mean = 43.04, SD ± 22.54), NOS (mean = 17.19, SD ± 1.85), NIA (mean = 2.95, SD ± 2.95), social Skills RL (mean = 62.04, SD ± 17.86), EL (mean = 56.28, SD ± 17.03), language (mean = 119.76, SD ± 32.83), and social (mean = 71.61, SD ± 20.04) (P < 0.005, 95% CI: 0.000–0.069) [Table 3].{Table 2}{Table 3}

The pretest and posttest scores of the control group [Table 3] were also analyzed through Wilcoxon signed-rank test which showed high negative ranks and a significance (P < 0.005, 95% CI: 0.000–0.069) explaining the control group also showed differences in their social skills after general play-based social skill training in the components of RL (mean = 62.04, SD ± 17.86), EL (mean = 56.28, SD ± 17.03), language (mean = 119.76, SD ± 32.83), and social (mean = 71.61, SD ± 20.04). In addition, to evident, the study analysis of the effect size has shown that the experimental group has been highly influenced by the Learn to Play program than the regular play-based intervention [Figure 1].{Figure 1}


Pretend Play - Play Indicators

From the observations of the pretest and posttest indicators of pretend play [Table 4], it was observed that the children in the experimental group had play deficits during the pretest but showed difference with indicators indicating typical play postintervention.{Table 4}

Nineteen children out of 21 in the experimental group showed the presence of typical play indicators and two did not show any difference explaining that the two children did not improve from the therapy. However, the control group did not show any difference in the pretend play between the pretest and posttest.

These typical play indicators in the experimental group lead to an understanding that the quality of a child's play in using various play scripts/scenarios, involving doll in a play, and trying to or establishing a narrative in their play has been developed after intervention. This can be referenced with a study where the typical play indicators were assessed and was found to have a positive correlation with social interaction 49% of shared variance, a 47.3% increase from the pretest scores,[4] proving that pretend play improved social skills of children with autism as listed in one of the objectives in this study.

Pretend Play and Social Competence

The result proves the fact that pretend play influenced developing and improving social competence in children with autism as mentioned in a study by the researchers.[5],[18]

A significant value (P < 0.005, 95% CI: 0.000–0.069) in the pretest–posttest comparison of the experimental group indicates that the components of pretend play, language skills, and social skills had improved, and the children also showed typical indicators of play which explains the significance value in the posttest.

These results from this study were consistent with the hypothesis testing of studies, which found a positive correlation between pretend play and social skills development,[19],[20] proving that pretend play has an impact on social skill development.[21],[22],[23]

The use of Learn to Play program to improve the social competence was found to be an important factor where the children participated in play used their play abilities and ability to interact with peers after a play intervention as discussed in the study[3],[4] between the children of play and nonplay interventions over 6 months.

A lacuna of a previously done study[4] was that comparison group did not undergo any kind of intervention when the experimental group underwent an intervention of Learn to Play thus showing no difference in the control group postintervention.

However, the scores of elaborate actions of pretend play [Table 4] and the RL, EL, language, and social skills of the social competence indicate that the control group has shared some improvement from the general play-based social skill therapy given in the present study. This would have led to a significant difference in the posttest scores of the control group in this study. Likewise, the object substitution component has not shown any significance. The findings of the effect size on the experimental group showed that the elaborate actions and object substitutions showed greater effect of d = 0.7 and d = 0.8, respectively, which is consistent with the study,[4] where the PEPA and NOS have improved 39.7% and 50%, respectively.

Moreover, the components, i.e. imitative actions, RL, EL, and total language showed a medium effect d = 0.3, d = 0.4, d = 0.3, and d = 0.4, respectively, which proves that the experimental group indeed has developed well after the intervention program. This explains that the pretend play is effective on improving social competence in children with autism. The control group on the contrary showed very small and unrated effect size of d = −0.2 to d = 0.1 in the components of pretend play and social skills which undoubtedly proved that the participants in the experimental group benefited from the pretend play inclusion in their regular therapy sessions, which was consistent with the findings from the study which proved that there was a positive correlation between pretend play and social competence in children.[3],[4],[5],[19]

Researchers[24],[25] on reviewing the evidence on pretend play and child development found effects that pretend play only assists development when an intensive adult interaction[26] is part of the training, and when there is no interaction, pretend play does not increase development.

Contradicting to the above given fact, in this study, pretend play among the children showed differences in interaction with adults as well as with peers. This variation is probably due to the participation of children in parallel level to cooperative level of social play. And also their involvement in participatory group play/activities among the peers that has led to the increase in social competence of children; integrated through Learn to Play intervention program.

Pretend play intervention was thus found to have an impact on the children's social skill development.

Limitations of the Study

Play and communication evolving in a natural environment would have affected the scores. Since the control group has also shown significance, to say pretend play alone has shown improvement after intervention is obscured. In addition, the evaluation timing of pretend play as provided by the scale may not be enough to analyze the performance of children. Research was limited to some geographical areas only with small sample size. Parents' awareness about importance of play and need to involve children in play was lacking.

Future Suggestions

Future studies to focus on the parent's perspectives[27] of pretend play should be encouraged. Use of pretend play and other play modalities such as integrated play groups[28] for two different groups to study the effect of pretend play must be focused. Pretend play to focus on other areas of skill development other than social competence using object substitutions and imitative actions should be thought of for further research.

Follow-up of the social competence[22],[29] and pretend play after 3–6 months is recommended as it might introduce a path for the vigorous use of pretend play as a therapy modality[30] in daily basis occupational therapy focusing on new arenas in child development.


The pretend play is an efficacious therapy modality to enhance social competence of children with ASD. It is summarized by the findings, which proved that the pretend play of the children in experimental group varies from children of control group by showing development in their social skills influenced by the pretend play.

All the components of pretend play, i.e. elaborate pretend actions, object substitutions, and imitative actions, and the components of social skills, including the RL and EL, show greater effect from the pretend play intervention.

The control group also shows an improvement implicating there was an effect from the regular play-based social skill training. However, as there were no statistically significant differences in control group, it is assured that the Learn to Play[11] program paved the way for these children to express their abilities and pretend play behaviors with their playmates with more enthuse.


We extend our very sincere thanks to the parents of the participants and the Head of Institutions for their support and cooperation. We extend our gratitude to our mentors for guiding and supporting us to complete the project and our family for their motivation at each step of the work.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.


1Howes C, Matheson C. Sequences in the development of competent play with peers: Social and social pretend play. Dev Psychol1992;28:961-974.
2Stagnitti K, Carolyn U. The importance of pretend play in child development: An occupational therapy perspective. Br J Occup Ther 2000;63:121-127.
3O'Connor C, Stagnitti K. Play, behaviour, language and social skills: The comparison of a play and a non-play intervention within a specialist school setting. Res Dev Disabil 2011;32:1205-1211.
4Stagnitti K, O'Connor C, Sheppard L. Impact of the Learn to Play program on play, social competence and language for children aged 5-8 years who attend a specialist school. Aust Occup Ther J 2012;59:302-311.
5Uren N, Stagnitti K. Pretend play, social competence and involvement in children aged 5-7 years: The concurrent validity of the child-initiated pretend play assessment. Aust Occup Ther J 2009;56:33-40.
6Lydon H, Healey O, Leader G. A comparison of video modeling and pivotal response training to teach pretend play skills to children with autism spectrum disorder. Res Autism Spectr Disord 2011;5:872-884.
7Kasari C, Chang YC, Patterson S. Pretending to play or playing to pretend: The case of autism. Am J Play 2013;6:124-135.
8Stanley GC, Konstantareas MM. Symbolic play in children with autism spectrum disorder. J Autism Dev Disord 2007;37:1215-1223.
9Jordan R. Social play and autistic spectrum disorders: A perspective on theory, implications and educational approaches. Autism 2003;7:347-360.
10Morrison J. DSM 5 Made Easy. The Clinician's Guide to Diagnosis. Neurodevelopmental Disorders, Autism Spectrum Disorder. New York, London: The Gulford Press; 2014. p. 50-58.
11Karanth P. Communication DEALL Developmental Checklists. Bangalore: Com DEALL Trust; 2007.
12Saxena-Chandok T, Ram-Kiran P, Lawrence L, Karanth P. The Communication deall developmental checklist – Inter rater reliability. Disabil CBR Inclusive Dev 2011;22:48-54.
13Karanth P, Shaista S, Srikanth N. Efficacy of communication DEALL – An indigenous early intervention program for children with autism spectrum disorders. Indian J Pediatr 2010;77:957-962.
14Stagnitti K. Learn to Play. A Practical Program to Develop a Child's Imaginative Play skills. West Brunswick, Victoria: Co-Ordinates Publications; 1998. p. 25-119.
15Case-Smith J, Allen A, Pratt P. Occupational therapy for children. In: Hinojosa J, Kramer P, Pratt P, editors. Foundations of Practice: Developmental Principles, Theories and Frames of Reference. Cognitive Theory of Piaget. 3rd ed. Maryland Heights, Missouri: Mosby Publications; 1996. p. 32-35.
16Case-Smith J, Allen A, Pratt P. Occupational therapy for children. In: Cronin AF, editor. Psychosocial and Emotional Domains of Behavior. Social Competence. 3rd ed. Maryland Heights, Missouri: Mosby Publications; 1996. p. 391-398.
17Case-Smith J, Allen A, Pratt P. Occupational therapy for children. In: Morrison C, Metzger P, Pratt P, editors. Play. Characteristics of and Contexts for Play, Use of Play as a Therapeutic Modality. 3rd ed. Maryland Heights, Missouri: Mosby Publications; 1996. p. 507, 511-516.
18Hobson JA, Hobson RP, Malik S, Bargiota K, Caló S. The relation between social engagement and pretend play in autism. Br J Dev Psychol 2013;31:114-127.
19Sebastianelli AL. The Relationship between Pretend Play and Cognitive, Linguistic, and Social Skills Development in Early Childhood: a Project based Upon Secondary Analysis of Developmental Screening Data from an Elementary School in Plainfield, Connecticut. Theses, Dissertations, and Projects. Paper 500; 2010. Available from: http://scholarworks.smith. edu/theses. [Last updated on 2016 Apr 12; Last accessed on 2016 Aug 27].
20Rutherford MD, Young GS, Hepburn S, Rogers SJ. A longitudinal study of pretend play in autism. J Autism Dev Disord 2007;37:1024-1039.
21Gitlin-Weiner K, Sandgrud A, Schaefer C. Play diagnosis and assessment: Developmental play assessments. In: Westby C, editor. A Scale for Assessing Development of Children's Play. – Play Scale. 2nd ed. New York, Chichester: Wiley Publications; 2000. p. 27-37.
22Denham SA, Blair KA, DeMulder E, Levitas J, Sawyer K, Auerbach-Major S, et al. Preschool emotional competence: Pathway to social competence? Child Dev 2003;74:238-256.
23Pfeifer LI, Pacciulio AM, Santos CA, Santos JL, Stagnitti KE. Pretend play of children with cerebral palsy. Phys Occup Ther Pediatr 2011;31:390-402.
24Lillard AS, Lerner MD, Hopkins EJ, Dore RA, Smith ED, Palmquist CM. The impact of pretend play on children's development: A review of the evidence. Psychol Bull 2013;139:1-34.
25Jarrold C. A review of research into pretend play in autism. Autism 2003;7:379-390.
26Fiorelli AJ, Sandra RW. Pretend play, coping, and subjective well-being in children. A follow – Up study. Am J Play 2012;5:81-103.
27Swindells D, Stagnitti K. Pretend play and parents' view of social competence: The construct validity of the child – Initiated pretend play assessment. Aust Occup Ther J 2006;53:314-324.
28Wolfberg P, Bottema-Beutel K, DeWitt M. Including children with autism in social and imaginary play with typical peers. Integrated play groups model. Am J Play 2012;5:55-80.
29Levenson R, Gottman J. Toward the assessment of social competence. J Consult Clin Psychol 1978;46:453-462.
30Stagnitti K. An investigation into the effect of play-based instruction on the development of play skills and oral language: A 6-month longitudinal study. J Early Child Res 2015;14:389-406.