Play interventions as a means to promote social engagement in preschoolers with autism. : A 2010-2020 Systematic Literature Review

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Play interventions as a means to

promote social engagement in

preschoolers with autism

A 2010-2020 Systematic Literature Review

Karteri Chrysiis

One-year master thesis 15 credits Supervisor

Interventions in Childhood Madeleine Sjöman

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2 SCHOOL OF EDUCATION

AND COMMUNICATION (HLK) Jönköping University

Master Thesis 15 credits Interventions in Childhood Spring Semester 2020

ABSTRACT

Author: Karteri Chrysiis

Play interventions as a means to promote social engagement in preschoolers with autism.

A Systematic Literature Review from 2010-2020.

Pages: 35

Children with ASD are characterized by impairments in socialization and communication, as well as by the presence of repetitive behaviours and limited interests. Their impairment often influences their participation in everyday ac-tivities and by extension their social engagement in playful acac-tivities with their peers is affected. Researches set play as the leading activity for a child’s development, because it is identified as the means that can deliver various mental tools and teaching strategies to preschoolers. Purpose of this systematic literature review is to identify play interven-tions that describe the procedures aiming in promoting the social engagement of preschoolers with autism. This review will also examine the people that implemented these interventions, in order to provide information and guid-ance for all professionals and educators that may need them. Search in the three databases, ERIC, CINAHL and PsychINFO was performed. Seven articles were found to meet all criteria and were divided based on the similarities on the design and the procedures that were followed. The results of the study led to three play interventions that used the ASAP and JASPER intervention programs in order to examine the social communication of children with autism leading to their social engagement. The remaining findings resulted in four different kind of interventions that use play as the context for either increasing social engagement or promoting engagement of students with ASD with their peers. These interventions include auditory, dance and video modelling interventions. The Zone of Proximal Development was used as the theoretical framework to support the ideas mentioned, since it points out the role of play in the child’s development. However, this study highlights the need for further investigation regarding the pro-motion of social engagement of preschoolers with ASD. The level of the social engagement of children with ASD are rarely investigated in the natural context of schools during their everyday peer-to-peer play interactions.

Keywords: play interventions, autism spectrum disorder, kindergarten, preschool, social engagement

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1 Introduction

Autism spectrum disorder (ASD) is a complex developmental disorder that affects one in every 160 children globally (Atladottir et al., 2015). Main characteristics are the severe absence of social and communication skills and the stereotyped and repetitive actions (American Psychi-atric Association, 2013). These characteristics of ASD often have an impact on the children’s participation in everyday activities and by extension they affect their engagement in playful conditions (Stagnitti & Cooper, 2009). The difficulty in engaging in meaningful interactions with peers and adults renders engagement in social interactions a challenge (Godin et al, 2017a).

Literature supports that the social difficulties of students with ASD are the core element of their disorder (Barnett, 2018). The National Research Council (National Research Council, 2001) presents some everyday situations, where children with ASD may have trouble engaging. Creating and maintaining relationships with peers, comprehending and responding to social communication “invitations” and participating in symbolic/dramatic play (National Research Council, 2001). When children with ASD initiate interaction, their communication efforts may seem abnormal to peers, due to their different patterns of social behaviour (Prizant & Wetherby 2005), leading to misunderstandings and disagreements (Marans et al., 2005). Delays in chil-dren’s communication and inability in comprehending other peers’ social cues reduce the de-velopment of mutual relationships between them (Godin et al., 2017a). For all the reasons men-tioned, social communication skills are considered a crucial instructional goal from the early childhood (National Research Council, 2001) and seem necessary for the promotion of social engagement (Godin et al., 2017a).

Barnett (2018) argues that, play acts as a means and provides opportunities to develop social skills across developmental domains and by extension provides opportunities for the sense of acceptance and intimacy to grow. Furthermore, play interventions are highlighted due to play being flexible and adaptable and able to be used across different conditions, objects, peers, and skills. Vygotsky, through his theory of “Zone of proximal development”, pointed out play as the means that delivers academic concepts and skills to preschoolers and gave an em-phasis on a child’s accomplishments when assisted (Bodrova & Leong, 2015). This idea is sup-ported by Lifter et al. (2011), who add that play provides an ideal context for practicing and generalizing new skills. However, in order for children with ASD to benefit from the relations and social interactions that occur during play, consistent and well-structured intervention is needed (Barnett, 2018), with play acting as the means and social engagement as the outcome.

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2 Background

2.1 Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a complex neurological disorder with significant difficulties in three wide parts of functioning: Social communication, interactions, and behaviour (Ameri-can Psychiatric Association, 2000). It often consists of impairments in communication, weak-ness in sharing interests, and difficulties in making and maintaining friendships. From the orig-inal conceptualization of Kanner’s (1943) to the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), difficulties in social relatedness have been the main charac-teristic of the disorder. People having a diagnosis of ASD, show inability in starting any type of social interaction (Hauck et al., 1995) and achieving joint attention (McArthur & Adamson, 1996), due to mostly using inappropriate greetings and behaviour (Hobson & Lee, 1998). Thus, individuals with ASD might refrain from participating in social interactions with peers and adults, making it even more difficult for them to experience appropriate social interactions (Boudreau & Harvey, 2013). It is worth mentioning that, the deficits in social relatedness follow people with ASD during their lifetime (Njardvik, Matson, & Cherry, 1999) as they mature and for that reason, the significant deviations from normal social interactions may constantly in-crease. Because Boudreau and Harvey (2013) studies the increasingly pervasive effect of social deficiencies through the lifetime of individuals with ASD, they highlight the need for the early implementation of successful evidence-based practices in a child’s development.

The limited and repetitive pattern of behaviour is another characteristic of ASD (Ar-mendariz & Hahs, 2019). Children with ASD are frequently engaging in repetitive motor move-ments or speech, reduced interests, and routine stabilization (Centers for Disease Control and Prevention, 2016). The characteristics above can be the cause for children with autism to often have reduced leisure skills. Following the same line, during free time, children with ASD might again engage in a limited and inappropriate range of activities. Sometimes, these activities are not even easily available across different settings and environments, due to accessibility (Ar-mendariz & Hahs, 2019). Solish et al. in their study (2010), found out that students with severe disabilities took part in less social and recreational activities in comparison to their typically developed peers. However, it is uncertain whether these deficits in leisure skills are caused by the individual’s diagnosis or by other structural limitations (Solish et al., 2010).

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2.2 Play

Using the definition of Neumann and Bundy, play is described as the “interaction between the individual and the environment that is intrinsically motivating, internally controlled, suspended from reality and framed” (as cited in Bundy, p 30). These characteristics are important for un-derstanding the play skills of children with ASD.

2.2.1 Play Types in Preschool Children

Parten (1932) introduced one of the most commonly accepted and used ways of classifying children’s play stages, by making a distinction between non-social play types of play including solitary play, unoccupied-, and onlooker behaviour and social types of play, consisting of asso-ciative and cooperative play. Specifically, when preschool children spend time observing or moving their body randomly without specific reason, their way of behaving is characterized as unoccupied, while preschoolers, who like to observe their peers and do not actually interact with them, their behaviour is defined as onlooker. Toddlers are frequently described as onlook-ers, but this behaviour occurs at any age. According to Parten (1932), solitary or, alone play, is presented when a child plays with toys or materials and is not interacting with other peers, even though they might be close to each other. As children are slowly starting to feel more comfort-able with their peers, they start engaging in social types of play. Associative play can be seen when young children start working with others, with some type of verbal interaction and playing with a common goal using similar materials (creating a building out of blocks) (Parten, 1932, as cited in Pozneanscaia, 2020). However, associative play does not indicate formal rules or roles. Later, and as children start to develop more social skills, cooperative play starts to grad-ually occur, within organized and structured activities with specific rules and roles. Lastly, in Parten’s theory (1932), parallel play concerns a distinct type of play and can be considered as a passing stage from non-social types of play to more complex and socially mature types, such as associative and cooperative. Children within parallel play can be found working in a similar activity or using similar tools but in an independent way without interacting with their peers (Parten, 1932, as cited in Pozneanscaia, 2020).

Overall, social types of play indicate a more complex form of peer interaction and de-mand a higher level of engagement. Thus, children are requested to have the ability to start, maintain and complete activities in a socially acceptable way (Lillvist, 2010, as cited in Pozne-anscaia, 2020). Children with ASD, who are unable to display social interaction properly and

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to externalize socially appropriate behaviour, is possible to spend less time and be less engaged in associative and cooperative play in comparison with their typically developed peers. Social engagement in a preschool setting is one of the main desired outcomes in Early Childhood Education (European Agency for Special Needs and Inclusive Education, 2017), and in con-junction with attendance, is suggested to complete the concept of participation.

2.2.2 The importance of Play

Starting from a more general point, play is a fundamental childhood occupation that is crucial for the child’s development, creating friendships with mutual respect and values and maintain-ing health and wellbemaintain-ing (Bundy, 2012). It appears to have a central role in the children’s de-velopment. From the cognitive and social-emotional parts, to communication, language and sensorimotor domains (Mastrangelo, 2009), play affects different parts of the individuals. Moreover, when children are engaged in play, they participate in occupations that have a mean-ing and develop skills that will be used long-term as a lifelong participant (Rigby & Rodger, 2006).

Neumann (1971) suggested three elements of play that comprised of intrinsic motiva-tion, perception of control and suspension of reality. Starting from the first characteristic, in-trinsic motivation is the participation in activities for personal satisfaction and joy instead of the need for external rewards and positive reinforcement (Bundy, 2004). Continuing to the sec-ond element, perception of control means the ability of a person to show self-control and take responsibility for their own behaviours and actions (Bundy, 2004). Lastly, suspension of reality refers to the relation and influence of using the real world in imagined conditions, commonly known as pretend play (Bundy, 2004). Moreover, Bundy took literature a step further and pre-sented a fourth characteristic that consists of framing. Framing is the ability to comprehend social cues, such as understanding verbal instructions and body language (Bundy, 2004).

In order to accept play as a means for developing skills, is important to deconstruct the term. Stagnitti (2010) proposed that the occupation of play is a two-phase activity. Apart from the actual development of skills (the ‘doing’ of play), the expression of who they are (the ‘be-ing’ of play) is similarly important. Mandich and Rodger (2006) added a third dimension, high-lighting the role of the player while engaging with others in meaningful interactions. Play has a spherical impact on the child and is a powerful tool for developing skills such as emotional control (Seja & Russ, 1999), social completion (McAloney & Stagnitti, 2009), language (McCune, 1995), problem solving (Russ, 1998) and narrative comprehension (Peter, 2003).

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2.2.3 Play and ASD

Literature shows that children with ASD have reduced play skills in most aspects of play com-pared to their peers without disabilities (Bauminger-Zviely & Agam-Ben-Artzi, 2014; Cham-berlain et al., 2007; Gunn et al., 2014; Skaines et al., 2006). For that reason, there is the as-sumption that the play patterns of these two groups show differentiation. Research proposes that many children with ASD have minimal skills regarding framing (Corbett et al., 2014; Evers et al., 2015). They struggle in the comprehension and communication of their emotions and providing and maintaining eye contact during interactions (Evers et al., 2015).

Bauminger-Zviely and Agam-Ben-Artzi (2014) and Gunn et al. (2014) through their studies agreed that children with ASD had problems engaging in more complex conditions that required imagination and pretend play in comparison to their peers. Following the same line, Chamberlain et al. (2007) recommended children with ASD have the ability to engage in some areas of play, but their play lacks complexity. In agreement are Gunn and his colleagues (2014), claiming that children with ASD have more possibilities to participate in solitary and parallel play than their peers and less possibilities to be engaged in role play and/or dramatic games. In total, these studies point out the difficulties, children with ASD face, when playing and the need to overcome them.

In order to appreciate the play skills of children with autism, more investigation on the different components of play is necessary to be done (Vousden et al., 2018). Social skills and actions are identified as important features during interactions between peers. Challenging be-haviours that can be detected by a child’s educator or therapist and may lead to social rejection and marginalization, is crucial to be limited, utilizing a wide range of techniques and practises (Petrina, Carter & Stephenson, 2014). Literature proves that children with autism possess de-layed social competences and by extension get involved in inappropriate behaviours (Gunn et al., 2014). In order to improve this competence, intervention programs may be needed (Petrina et al., 2014). Petrina, Carter and Stephenson through their study (2014), suggested that social engagement and play interactions of children with ASD can be reduced on account of social obstacles that may appear through interplay among peers. Similarly, peer interactions can sup-port the development for both childhood and friendship (Gunn et al., 2014).

As stated above, a great number of children with ASD have less developed play skills (Dominguez et al., 2006) and their state of playfulness disagrees with those of children with typical development (Skaines et al., 2006). Although, functional play can be demonstrated by

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children with autism, elements of playfulness are missing (Hobson, 2009). Hobson and his col-leagues (2009) pointed out that, when children with ASD are involved in creative, social and pretend play, issues can be observed. They seem to lack the ability for spontaneous initiation and to react when other peers interact with them socially (Restall & Magill-Evans, 1994; Skai-nes et al., 2006). This fact points out the need for investigating the role of play in promoting social engagement. The problems that often influence a child’s play are related with the basic elements of this disorder, highlighting the lack of social mutuality, reduced emotional regula-tion and absence of social engagement (Restall & Magill-Evans, 1994).

2.2.4 Context of Play

Children with ASD show repetitive and stereotyped behaviours and have limited interests, that may lead to having difficulties in playing, initiating and maintaining a discussion and by exten-sion influencing their everyday interactions (Gunn et al., 2014). However, the environmental conditions affect the play experience children engage in (Kielhofner, 2008). Play and social competences may vary based on a child’s surrounding systems and consequently, it is signifi-cant to make observations within natural conditions. (Vousden et al., 2018). Some of the dif-ferent aspects of the environment that affect the children are presented below. Vousden and her colleagues (2018), supported that school is a realistic setting that offers students opportunities for peer to peer interactions. Research suggests that children prefer engaging in play with peers that are friendly and of the same age, while being in an intimate and relaxed environment (Bauminger-Zvie & Agam-Ben-Artzi, 2014). It is reasonable to assume that sharing play expe-riences with familiar peers promotes peer to peer interactions in general (Wolfberg et al., 2015).

2.3 Social Engagement

As mentioned above, students with disabilities can be influenced by environmental features, that by extension can lead to affecting their social engagement (Kielhofner, 2008). Prohaska, Anderson and Binstock (2012) suggested that the term “social engagement” frequently con-cerns an individual’s participation in the activities of a social group. Following the same line, Avison, McLeod and Pescosolido (2007) used the term to refer to “the extent to which a person participates in a broad range of social roles and relationships” and subsequently the term was completed by Zhang, Jiang, and Carroll (2011), who made an addition describing social engagement as “the commitment of a person to stay in the group and interact with others”.

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Quality interactions with both peers and adults can help children participate in the social context of the classroom and the possibility of maintaining effective and positive relationships with educators can act as a facilitator in the learning procedure (Tsao et al., 2008). Pianta and Stuhlman (2004) identified encouraging connections between the teachers’ way of interaction and the students’ academic performance. On the contrary, negative interaction between students and their teachers may show a kind of social participation that could negatively influence the advantages that children with disabilities receive from their classrooms (Pianta & Stuhlman, 2004). Following the same line, social engagement with peers may lead to encouraging results on a child’s social, play, and communication skills (Jenkins et al., 1989; McGee et al., 1993; Guralnick et al., 1996). In addition, social engagement relates to social acceptance of children with disabilities by the typically developing co-students in the school settings, in comparison with negative social interaction being connected with social rejection and isolation by peers (Odom et al., 2006). Nevertheless, although studies display play as a great tool for promoting social engagement, the behavioural and social skills of children with ASD, while engaging in play activities and interacting with their peers, have been rarely investigated using observational measures within the natural context of school (Vousden et al., 2018).

2.3.1 Teacher - Student Relationship

It is evident that, an interesting connection between adult behaviour and peer interaction in children with disabilities occurs (Tsao et al., 2008). The quality of this relationship is recog-nized to an increasing extent as a contributor to school success (Birch & Ladd, 1998; Pianta et al., 1995). A comparable relationship to the parent and children relationship is the teacher-child relation that seems to act as a functional regulator regarding a child's social and emotional de-velopment (Greenberg et al., 1993). Teachers act as mediators of student’s success, using dif-ferent means and tools, in this case difdif-ferent types of play. Burchinal et al. (2002) add to the literature that the connection between teacher-child intimacy and student’s development is greater when children are in kindergarten rather than when they attend early elementary school. However, literature proposes that the presence of an adult for the support of students with disabilities during their relationships with peers might reduce or even eliminate the possi-bility for steady and uninterrupted interaction (Strain & Fox, 1981). Strain and Fox, through their study (1981), found out that, when educators co-interact with students, even for providing stimulus for social interaction, the children may shift their attention from peers and initiate

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interactions with adults. On the other side, Sontag (1997) in her study of environmental factors influencing the social participation of children with disabilities, highlighted that the verbal in-teractions with peers have been increased, when educators supported children with prompts. As mentioned before, comparing these two types of research, it can be ascertained, that adult social behavior towards children could act as a facilitator or a barrier of social interaction with peers.

2.3.2 Behavioural Requirements

There is a clear transactional and reciprocal relationship between behavior of children and es-pecially those with autism and their social engagement. Behavioural changes can be seen as prerequisite of social engagement. Within a school setting, children are required to make im-portant alterations in both social and behavioural levels (Williams et al., 1989). Williams and his colleagues (1989) propose that, these adaptations include not only compliance to the behav-ioural demands of classrooms that are set and controlled by their teachers, but acceptance and compliance to the behavioural demands and social interactions of free-play activities that are formed by peers. However, in most occasions, children with ASD do not have the expected social skills to meet the behavioural requirements and expectations of the school setting, neither possess the ability to participate in the positive social connections with either adults or peers within this environment (Gresham, 1982).

In free-play conditions, especially on the playground, children are required to show social competences in order for peers to accept them and allow them to be involved in the continuously peer-controlled activities (Boudreau & Harvey, 2013). If children want to develop and engage in meaningful peer relationships, it is important to initiate and maintain interactions with others, understand and respond properly to others’ initiations, provide assistance to children that need it, allow interactions either as dyads or groups with peers, being able to play games and com-municate sufficiently with their peers. (Walker et al., 1994). However, many children have in-adequate skills to show the types of behaviour mentioned above and the possibilities of being marginalized by their peers increase (Odom et al., 2006). Odom et al (2006) highlight the need for protecting these children and incorporating them to the educational process.

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2.4 The Zone of Proximal Development (ZPD)

From all the statements above, it is reasonable to take into account Vygotsky’s view on child development and use his theory on how social factors and social interaction play an essential role in children’s development (Powell & Kalina, 2009). This theory is called “Zone of proximal development” (ZPD) and was first presented in the 1920s (Bodrova & Leong, 2015). ZPD includes the space between the condition of a child’s development without support, the independent accomplisments and the actions that a child can achieve through guidance either by adults or peers (Bodrova & Leong, 2015). It focuses on the way that mental development occurs using assisted activity (Bøttcher & Dammeyer, 2016). This idea highlights that development is a procedure, where skills and practices are implemented with assistance (interpersonal) and after that the child adds them in their acquired abilities (intrapersonal) (Bøttcher & Dammeyer, 2016). When a child reaches the goal learning an activity, their zone expands and they are able to achieve more (Powell & Kalina, 2009).

This theory can be seen in all kinds of activities, formal and informal (Bøttcher & Dammeyer, 2016). Bøttcher and Dammeyer through their book (2016), pointed out that the child’s ability to imitate an activity leading to enhancing their development can be achieved in different settings, by different sources. A teacher giving instructions and providing assistance in a formal learning condition, in a regular preschool environment and on the opposite side, a mother or a family supporting their child by creating opportunities for learning, can both act as a successful means of potential development (Bøttcher & Dammeyer, 2016). Families through their everyday routines and usual discussions offer great stimuli for practicing cognitive skills, such as memory (Edwards and Middleton, 1988). According to Edwards and Middleton (1988), looking at pictures from vacations, for example, and having simple and relaxed talks between young children and parents, make more than enough appropriate circumstances for practicing skills in remembering. The ZPD concept places social interaction in the core of a child’ devel-opment process (Bøttcher & Dammeyer, 2016).

It is important to understand that ZPD is the space between a child's actual mental con-dition and the concon-dition a child could achieve with both experience and support, a level where people reach when participating in settings of intellectual development (Bigge & Shermis, 2004). The core in Vygotsky's ZPD theoretical framework is “support” and “experience” (Powell & Kalina, 2009). However, these concepts are important to be identified at a realistic level, so that the desired goals can be relevant and achievable for the child aiming in learning (Powell & Kalina, 2009).

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2.4.1 ZPD and ASD

Activities at a group structure can show the ZPD of children close in age, but for students in need of special support, this work becomes more difficult (Bøttcher et al., 2016). For children with disabilities and especially those with autism that attend mainstream schools and are as-signed to group activities, might be more challenging to address their ZPD, due to their diffi-culties and the different level of development between them and their classmates, but it is not impossible (Bøttcher & Dammeyer, 2016). Vygotsky was a strong supporter that social inter-action and environmental elements have a great impact on children and their possibility of learning (Powell & Kalina, 2009). In the context of inclusion, typically developed students and students with ASD are important to get opportunities to engage in (Bøttcher & Dammeyer, 2016). Powell and Kalina in their book (2009), pointed out the obligation that educators have, to detect the heterogeneity of their classrooms, accept it and use it for all students’ benefit. The most important part in ZPD concept is to identify each child’s zone and accurately determine the goal and the means, which will be used to achieve the desired outcome (Bøttcher & Dammeyer, 2016). Teachers have the responsibility and the position to act as mediators, for students with ASD to interact with their peers and share their diversity (Powell & Kalina, 2009).

2.4.2 ZPD and Play

Vygotsky, taking into consideration the early childhood and its crucial role in the child’s development, was able to identify the medium that would deliver a wide range of mental tools and teaching strategies to preschoolers without pressure and compulsion, but in a more natural way, leading him to play (Powell & Kalina, 2009). Vygostky was a huge believer that play has its own role in the child’s development and presented his opinion on play acting as a successful means of carrying academic ideas and abilities to students attending kindergartners and preschools (Bodrova & Leong, 2015). In Vygostky’s book (1967), play is accepted as the main and most essential source of development during preschool years and the priming for the exist-ence of the zone of proximal development. Having an active imagination, creating and engaging in the imaginery situations and obeying on the enviromental rules that exist, makes play the highest and most meaninigful level of preschool development (Vygostky, 1967). In order for a child’s social engagement to be promoted, specific types of play can point out its ZPD. In as-sociative, cooperative and parallel play, where social engagement is required, children are be-coming more comfortable with their peers and start acquiring more social competence. Pre-schoolers might shift from working alone, to engaging in organized activities.

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As stated by Bodrova and Leong (2015), play acts as an effective medium to bring academic ideas and competences to children at preschool age. However, they follow saying that, being assisted by adults or more educated peers, could be limited in one-on-one conditions of teaching. Play expands this concept by bringing students and children together and stimulat-ing mental procedures that can only function when the child is cooperatstimulat-ing with another human being (Smolucha, 1992). According to Elkonin (1978), play supports children of today to de-velop general skills that will allow them to handle and control any challenge that they may face in the future. Preschoolers expand their knowledge while playing, by practising their self-con-trol, their patience, by cooperating and socializing (Glover, 1999). Specifically, they are re-quired to share their objects, make negotiations and arguments regarding choosing activities and respect their co-students (Samuelsson & Carlsson, 2008).

2.5 Rationale

As mentioned in the previous sections, children with ASD have repetitive and stereotyped be-haviours, as well as limited interests (Gunn et al., 2014). Their condition often influences their participation in everyday activities and by extension their engagement in playful activities is affected (Stagnitti & Cooper, 2009). Research defines play as the leading activity for a child’s development, because it is recognised as the means that can deliver various mental tools and teaching strategies to preschoolers (Powell & Kalina, 2009). However, social engagement concerns the types of play, that involve working with others, with some type of verbal interac-tion and playing with a common goal using similar materials. Therefore, the weakness of chil-dren with ASD in engaging in meaningful interactions with their classmates and adults makes playful engagement in social interactions a challenge (Godin et al., 2017a).

Barnett (2018) suggests that, in order for the interactions that occur during play to be valuable and helpful for children with ASD and to continue to develop their play skills, the need for continuous and well-organized intervention programs stands out. However, there are gaps in the current literature assessing the behavioural and social skills of children with ASD while engaging in play activities within the natural context of school (Vousden et al., 2018). This thesis aims to identify the available play interventions applied to preschoolers with ASD, be-cause the extracted information can be support and guidance for professionals working with these children.

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3 Aim

The purpose of this systematic literature review is to describe the play interventions that focus on promoting social engagement in preschoolers with autism. It aims to answer two research questions:

1. What play interventions in preschool settings aiming in promoting social engagement among children aged 2-6 years old with ASD are available?

2. Who can implement the play interventions in preschool settings to children aged 2-6?

4 Methodology

4.1 Systematic literature review

To identify research on the purpose of this study, a systematic literature review was performed. Out of the different research methods available (Grant & Booth, 2009), systematic literature reviews are believed to address fully and suitably the aim presented and are designed to offer a complete and comprehensive summary of current evidence relevant to clear and well-defined research question(s). Through organized, transparent and reproduceable procedures, data were collected and analyzed and then findings were synthesized qualitatively and quantitatively. During the search and collection method, both inclusion / exclusion criteria and quality assess-ment criteria were defined (Jesson et al., 2011).

4.2 Search procedure

The database search for this systematic literature review took place in January 2020. With the assistance of a qualified teacher, electronic searches were conducted using three web-databases ERIC, CINAHL and PsychINFO for articles published between 2010 and 2020 using a combi-nation of keywords and MeSH terms (Table 1). All the searches were limited to scholarly arti-cles published in the English language. Specifically, the web-databases were accessed through the Jönköping University’s electronic library. The databases provide access amongst others to education, psychology, anthropology, sociology, psychiatry, medical and arts literature. In all databases three filters were applied based on the inclusion and exclusion criteria that were set (i.e. English language only, 2010 to 2020 only, peer-reviewed only). The same search words were used in all databases and can be presented subsequently.

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• “play OR playing OR play based learning OR play interventions” AND “social engagement OR social participation OR social involvement” AND “kindergarten OR preschool OR early childhood education OR preschoolers” AND “autism OR asd OR autism spectrum disorder OR autism spectrum disorders”.

The participant, interest and outcome (PIO) framework was used in order to highlight the spe-cific components necessary for the aim of this review.

Table 1

Search terms

Population Intervention Outcomes

Diagnosis Age range ‘autism’

‘asd’

‘autism spectrum disorder’ ‘autism spectrum disorders’

‘kindergarten

(mainstream or special)’, ‘preschool’,

‘early childhood education’, ‘preschoolers’

‘play’, ‘playing’

‘play based learning’, ‘play interventions’

‘social engagement’, ‘social involvement’ ‘social participation’

4.3 Inclusion/exclusion criteria

Inclusion and exclusion criteria used for the screening, were used regarding behaviours, popu-lation, approaches/strategies and were established based on the research questions. Firstly, there is a need to investigate the play interventions that are available, that aim in enhancing social engagement among children aged 2-6 years old. Secondly, there is an interest in recognising the different occupations that are able to perform play interventions to promote social engage-ment to children aged 2-6. Studies targeting preschool-aged children (2–6 years) with ASD were included, since children are diagnosed with ASD at a younger age than in the past (Newschaffer, Falb, and Gurney, 2005), and the interest was in the early interactions between the child and the school environment. A possible extraction form with inclusion and exclusion criteria is shown in the Table below.

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Table 2

Presentation of the Inclusion and Exclusion criteria applied through all the studies’ exami-nation stages.

Inclusion Criteria Exclusion Criteria Population Children aged 2-6

Children with Autism Spectrum Disorder

Infants 0-1 Children 7-12 Teenagers 13-18 Adults 18+

Typically developing children Interest Autism spectrum disorder with or

with-out intellectual disability as comorbidity

Other syndromes and comorbidi-ties

Outcome Social engagement of children in play ac-tivities in preschool/kindergarten

Social engagement in health set-tings

Social engagement in home set-tings

Other types of engagement: cog-nitive and behavioral engagement School Competences and Aca-demic Performance

Publication Research articles and studies published in peer-reviewed journals

Qualitative studies Quantitative studies

Book chapters, reports that are not peer-reviewed, scoping review Systematic reviews

Availability Available in full text

Available in English language

Only abstract available

Year 2010-2020 Older research

Caregivers Specialists Teachers

Parents

Other family members Intervention Interventions conducted in preschool or

kindergarten settings

Interventions conducted in home settings

4.4 Title, Abstract and Full-Text Screening

There were 71 studies matching the search threads that were used in the databases. Specifi-cally, in ERIC the search resulted in 15 articles, while in CINAHL there were 19 available articles. Lastly, in the PsychINFO search, 37 articles were found. Using the Zotero tool for extracting the 71 articles from the databases, 19 studies were excluded as they were identified as duplicates. After carefully examining all 52 articles in the primary examination on title and

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abstract level based on the inclusion and exclusion criteria set, 29 were excluded from the fur-ther analysis, mostly due to different target and role of play(e.g. play as outcome instead as means) or wrong setting (health and home settings), leaving 24 articles for secondary full text examination. Inclusion and exclusion criteria were again applied to the 24 articles included for full-text screening process. During this screening, the focus was largely on the method section where interventions were described, since the goal was to describe the play interven-tions available and the procedures for promoting social engagement.

Finally, from the 24 examined studies, one was not available in full text, one study was completed in wrong setting (home environment), 2 articles were excluded due to different per-sonal information of the participants (age, N=1; presence of comorbidities, N=1), 10 were ex-cluded due to different aim and intervention focus (no focus on play as means but play as out-come, N=4; joint attention related, not relevant for the study, N=2; completely different target, N=4 ), one study included a combination of exclusion criteria (age, presence of comorbidities, play as outcome, not as means) and 2 articles were excluded due to absence of play (only social engagement related). After the exclusion of 17 articles, 7 remained for data extraction. The screening process is pictured in a flowchart below and summarizes the procedure followed.

4.5 Data extraction

Data extraction was performed using a protocol presented in Appendix A. Extracted information was consisted of authors, title of the article, year of publication, study location (country where research took place), study aim and purpose, research questions and hypothesis. The general information were followed by methodology data and specifically, information about the sample of children (number of participants, gender, age, whether there was diagnosis of ASD or not), study design, data about the interventions (type, setting, theory, goals, outcome), data collec-tion, how and from where were the participants recruited, sampling method, whether there was a control group, data analysis, results, limitations and conclusions discussed in the article.

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Table 3

Flowchart showing the search procedure

ERIC

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Full text screening

23 7 CINAHL PsychINFO 71 19 37 19 duplicates Excluded: 34 • Lack of intervention • Play as outcome, not

as means • Family settings • Parents’ interventions • Language and speech

interventions • Different age of

children • Presence of

comorbidities • Not studies, but

presentation of interventions

• No full text available

Excluded: 16

• No full text available (N=1) • Wrong setting (N=1)

• Different age of children (N=1) • Presence of comorbidities (N=1) • Different Target (N=5)

• Play as outcome, not as means (N=4)

• Combination of exclusion criteria (N=1)

• Absence of play (N=2) Abstract and Title screening

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4.6 Ethics

This systematic literature review investigates children’s behaviour, so ethical considerations was important to be taken into consideration. The Economic and Social Research Council Re-search Ethics Framework (2005), recognizes six key concepts of ethical reRe-search for partici-pants, which are the assurance of integrity and quality, respect of the confidentiality and ano-nymity, accepting that involvement must be voluntary and lastly, harm prevention. It is crucial to understand that these principles are applicable to young children (Bell, 2008). For all the reasons mentioned, the articles that were included in the study, it was essential to have an ap-proval from an Ethics committee. All the information that were obtained from the articles, were stated and described with complete transparency and honesty. Issues regarding the ethical con-siderations of the selected articles can be observed in the discussion section 6.2.2.

4.7 Quality assessment

Quality assessment of the final articles was performed using the CASP checklists for quantita-tive and qualitaquantita-tive research (CASP, 2017). For the articles that were identified having a mixed method design, both the CASP qualitative checklist and the CASP cohort study checklist were used. No modifications were made. The protocol is shown in Appendix B.

The process that was followed started with a general read through each one of the stud-ies. Next, decision was made regarding the design of the study that was described in the articles, a procedure that was followed by choosing the CASP tool that is relevant to the type of the study, Finally, the studies answered the CASP questions and a score came out, based on whether they meet specific quality criteria or not. The questions concerned the aim of the studies, the data collection, the data analysis, the results of the studies and their validity and precision, the ethical considerations and further implications. When an article scored 50% or lower of the quality criteria, it was considered to be of low quality. The medium quality articles were those that scored between more than 50% and less than 70%, while the high-quality articles were the ones having between 80% - 100% of the quality criteria fulfilled. Specifically, two of the arti-cles were reflected to have good quality (>70%), four artiarti-cles were of medium quality (>50% and <70%) and one article was of low quality (<50%). However, the one low-quality article that was identified, was not excluded from the systematic review, due to the number of the studies included being relatively small.

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4.8 Data Analysis

Data analysis is the last step of the methodology and was executed during and after data extrac-tion. A reference number was set to each study (Table 2) and was used throughout the whole procedure of the data analysis. The general information about the studies and the intervention programs that were used, including the country of conducting the study and the methodology design, were analysed to get an overview of the different tools and processes that they followed, aiming in promoting social engagement in preschoolers with autism.

This systematic literature review followed a relational thematic data analysis. The the-matic data analysis, among other things, is used to reveal patterns in communication contents and it is usually applied to a set of texts (Clarke & Braun, 2016). This relational content analysis started with identifying the research questions. Then, the search terms in the databases during the search procedure showed specific findings, that led to the selection of different texts for analysis. The data were closely tested to identify common themes and topics, ideas and patterns of meaning that were presented repeatedly. This process led to the results of this review.

The analysis had a deductive approach, since the data were examined in order to find some preconceived themes that were expected to be found, based on literature and existing knowledge. Aim of this systematic literature review was to address fully and suitably the play interventions that can be used to promote the social engagement of preschoolers with autism and offer a complete and comprehensive summary of current evidence relevant to the research questions.

The next section includes the results of this review and are presented similarly to the data analysis. Furthermore, the “Results” section contains more details about the interventions’ organisation and execution.

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Table 2

Overview of articles and intervention programs

IN* Name Authors (Year) Year Country Design Intervention

1 Does music matter? The effects of background music on verbal expression and engagement in children with autism spectrum disorders.

Preis, Amon, Silbert-Robinette & Rozegar.

2015 USA Mixed Method Music Intervention

2 Efficacy of the ASAP Intervention for Preschoolers with ASD: A Cluster Randomized Controlled Trial.

Boyd, Watson, Reszka, Sideris, Alessandri & Baranek.

2018 USA Quantitative ASAP Intervention

3 Preschool Based JASPER Intervention in Minimally Verbal Children with Autism: Pilot RCT

Stickles Goods, Ishijim, Chang & Kasari

2013 USA Quantitative JASPER Intervention

4 Preschool Deployment of Evidence-Based Social Communication Intervention: JASPER in the Class-room

Chang, Shire, Shih, Gelfand & Kasari

2016 USA Quantitative JASPER Intervention

5 Teaching games to young children with autism spec-trum disorder using special interests and video model-ling.

Jung& Sainato 2015 USA Mixed Method Video Modelling Intervention

6 The effect of sung speech on socio-communicative re-sponsiveness in children with autism spectrum disor-ders.

Arkoprovo, Sharda, Menon, Arora, Kansal, Arora & Singh.

2015 India Qualitative Auditory Intervention

7 Use of a creative dance intervention package to in-crease social engagement and play complexity of young children with autism spectrum disorder

Nelson, Paul, Johnston, & Kidder.

2017 USA Mixed Method Dance Intervention

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5 Results

5.1 Overview of the results

Seven articles were identified to fulfil the inclusion criteria and answer the research questions regarding the availability of play interventions in promoting social engagement in preschoolers with autism. The research questions get responses, either by observing a change in outcomes from intervention, or by comparing the results to a control group, or by combining these two kinds of data. The articles were published between 2010 and 2020 in peer reviewed journals. An overview of the studies with the most important information is listed above in Table 2.

Out of the seven studies included in this systematic literature review, six were set in the USA (1,2,3,4,5,7) and one in India (6). Three studies were quantitative (2,3,4), one was quali-tative study (6) and three were mixed method studies (1,5,7). Information about the search de-sign, the content of the studies and the procedures of the interventions are presented below.

5.2 Search Design

5.2.1 Design

There were certain similarities that could be identified in the search design of its study. Out of the seven studies, three had both control and treatment groups, in order to observe possible changes in the treatment group and comparison to be made (2,3,4), while the remaining studies reported the outcomes of the same participants while being in two different settings (1,5,6,7). The three articles that incorporated the control group (no treatment) to examine change over time were the same articles that tested the success of the ASAP and JASPER interventions (2,3,4). For the remaining four studies (1,5,6,7), 2 different settings were used, one with no-treatment/no-exposure condition and one with exposure condition, in order to observe and com-pare the same skills of the same participants in both environments. Every activity was per-formed in both settings.

Three articles had a follow up after the intervention took place (4,5,7), in order to ex-amine the initial skills but after the exposure of the intervention. In all studies, the “Follow up” took place for one month after the study and it was the third or fourth part of the entire program. The children played the intervention activities and all processes were similar to the baseline setting.

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5.2.2 Sample

The sample of the studies varied, from 3 to 161 participants. All of the studies included children aged from 2-6 years old with a diagnosis of ASD, based on the inclusion criteria of this system-atic literature review. However, three articles used children without disabilities in their inter-ventions as play partners (1,5,7). The participation of the typically developing children was either passive, with students not interacting much with the children with ASD but just being in the classroom since the intervention was conducted in their typical classrooms or active, where they were encouraged to interact with the children with autism and continue their play. In one of the studies (5), the ratio of the intervention was 1:2, with one child with ASD interacting with two typically developing students. The remaining four articles observed only the children with autism (2,3,4,6), with no play partners.

5.2.3 Measures

Out of the assessment tools that were used for measuring the data, one of them was completed in three studies (2,3,4). The Structured Play Assessment (SPA) is an experimental measure of play that it is used at different parts of an investigation, pre- and postintervention, at baseline, entry and exit. After that, the tool is coded for play types, measuring the play diversity that estimates the number of unique, spontaneous and functional play acts (Lifter et al., 1993).

The investigators of one of the studies (7) measured social play when the 15 second period of time included children engaging in contextually appropriate play close to play partners and making eye contact with them, as well as associative or cooperative play at least once in the interval. In the same intervention, engaged time was described as time spent in close dis-tance of a learning center using play materials in a developmentally and contextually acceptable way or interacting with peers.

For measuring the social engagement of the participants, the instruments were differen-tiated by each studies’ researchers. In one of the investigations (2), preschoolers’ social engage-ment was observed during their normal classroom routines and data were collected. At the end of each observation, the expert graded the child’s total level of involvement using a 5-point Likert scale, ranging from 1-non engaged to 5-very highly engaged.

The researchers of another study (1), collected data for two measures. Firstly, for the frequency of spontaneous verbal interactions of participants to either peer or adult and secondly, for the social responsiveness or engagement. The social responsiveness or engagement was

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measured by the frequency of disengagement (absence of response to the communicative stu-dent’s offer, interrupting an interaction with a peer or ignoring an activity). Interval scoring was used for data collection, where the 30-minute time period was split into continuous sections of three minutes, allowing equal observations for each student during the treatment conditions.

One study (3) used the Classroom Observation Measure (Wong and Kasari, 2012), that was designed to observe states of engagement and spontaneous communicative gestures during 20 min of free play in the classroom, with the child’s classroom teacher and/or aides being present before and after the intervention. Engagement states were categorised as unengaged, object, onlooking, person, supported joint, or coordinated joint engagement. The measure was divided to 50 s observing and 10 s coding.

Another’s study researchers (5) decided to divide the different types of engagement and observe the participants. Specifically, engagement with the game was split into verbal and non-verbal engagement. “Verbal engagement with the game” was described the participants’ own behaviour in play actions or materials related to the activity. “Nonverbal engagement with the game” was set the behaviour of the participant that is characterized by contextually appropriate movements, such as looking at the game or displaying play actions related to the game. “Verbal social engagement with peers” was described when participants verbally initiated, responded, or/and made comments to other peers. The “nonverbal social engagement with peers” behaviour was characterized with eye contact, taking turns, cooperating with their play partners, sharing materials, pointing at others or/and exhibiting gestures and play actions toward the play partner. In one of the studies (6) the socio-communicative responsiveness was measured using two different behaviors, social gesture and eye contact. The participant’s response physically to social greeting (hi five) was named “social gesture” and was measured from the percentage of cases of social gestures in combination with the total number of opportunities offered from the interventionist. “Eye contact” was measured from the percentage of frequency of the par-ticipants’ eye contact in combination with the total number of instances their name was called by the interventionist.

5.2.4 Content

Out of the seven articles, four dealt with types of interventions that use play as the context to achieve their goals (1,5,6,7) utilizing other primary tools. Specifically, 4 concepts, music (1), technology (5), audio (6) and dance (7), were incorporated as the tools creating interventions

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that were executed, while children were playing. They tested the possibility of these concepts during play activities acting as a tool for encouraging preschoolers’ social behavior and increas-ing engagement and communication.

The rest of the studies were concerned with interventions that used play as the direct medium of intervention (2,3,4). From these three play interventions studies, two of them have implemented the JASPER program (3,4) and one was related with the ASAP program (2). However, both interventions are modifications and expansions of the original joint attention and symbolic play (JASP) interventions developed by Kasari et al. (2006, 2008). Purpose for all three studies was to investigate the effectiveness of either the advancing social-communica-tion and play intervensocial-communica-tion program (ASAP) (2) or the Joint Attensocial-communica-tion, Symbolic Play, Engage-ment and Regulation intervention (JASPER) (3,4) on preschoolers with autism. The duration of the ASAP study was 4 years, while the JASPER lasted 3-4 months.

From a content level, out of the seven articles, two studies used auditory interventions to support their goals (1,6), regarding the promotion of social engagement and communication in preschoolers with ASD. Specifically, the first study (1) tests the possibility of background music during play activities acting as a tool for enhancing preschoolers’ social behavior and increasing engagement and communication. The second investigation (6) examines the possi-bility of sung instructions, in comparison to spoken instructions, causing higher levels of social and communication engagement in preschoolers with autism. Both studies focus on auditory stimuli, where in one case (1) the impact of background music was measured by estimating every student’s meaningful engagement while participating in structured play. The study used 2 different settings, one with no-treatment/no-music condition (A phase) and one with back-ground music condition (B phase), in order to observe and compare the same skills in both environments. Both studies highlight the importance of music and audio in a child’s develop-ment, especially those with autism.

None of the selected articles reported the relationship between interventionists and par-ticipants. In studies, where the interventionists were consisted of classroom teachers and teach-ing assistants, zero information regardteach-ing the quality of the teacher-preschooler connection were mentioned (2,4). Even in the studies, where the interventionists did not belong to the school team and were new professionals assigned to complete the interventions (3,6,7), no in-formation about the first contact and meeting between them and the students were reported. In one of the studies (1), it did not even become known whether the different professions already knew the participants or not.

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5.2.5 Procedures

This section includes details about the process that each intervention followed in their study. The first study of the results of this systematic literature review is an article (2) that investigates the effectiveness of the advancing social-communication and play intervention program (ASAP). The ASAP program aims in the reduction of educators’ exhaustion when teaching children with autism, as well as the promotion of pre-schoolers’ social interaction and partici-pation in classrooms. Important components for ASAP are both 40 min interaction with each student divided across the week and minimum three group activities every day, aiming in ex-tending the student’ chances for learning and practicing the currently set skills.

The intervention started with the preschool teams receiving two educational programs during the school year, with the first presenting an introduction to ASAP, with theory and basic elements regarding social-communication and play, lasting four to six hours in total. The second training covered issues about the ASAP execution potential challenges and lasted two to three hours. The ASAP intervention includes a control group, that followed their regular practice and did not receive any assistance or guidance from the trained ASAP teams. After the training, the preschool teams of the treatment group reported the social-communication goals chosen for each student, information about the selection of these goals and then implemented the ASAP intervention. Preschoolers were observed during their normal classroom routines regarding so-cial engagement and data were collected. At the end of each observation, the expert graded the child’s total level of engagement using a 5-point Likert scale, ranging from 1-non engaged to 5-very highly engaged.

The next study (3) tested the effects of Joint Attention, Symbolic Play, Engagement and Regulation intervention (JASPER) on minimally verbal preschoolers with autism. Focus of the study was students who do not make remarkable progress in social and communication skills, but instead, show slow to minimal improvement. The JASPER intervention started with all children receiving baseline assessments before the start of the study. After 3 months, the same children completed entry assessments to confirm the stability of the targeted skills and then each participant was randomly selected to participate in either control or treatment group. Both groups’ professionals continued assessments and classroom observation. Students in the control group, followed the standard classroom practice for 30 hours per week. Preschoolers in the intervention group followed sessions with 30-minute duration two times per week for 3 months. After the sixth month, both groups completed exit assessments to examine potential change in

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play types, social communication and different kinds (object, person) and levels of engagement (unengaged, onlooking).

The systematic review resulted in one study (4) that is the implementation of the Joint Attention, Symbolic Play, Engagement and Regulation intervention (JASPER) and examines the success of this program. For one teacher, two children were corresponded, creating a ratio 1:2. The intervention program started with both target selection and training of the involved teachers. The current study modified the JASPER model to adjust to the needs of the teachers of the preschool settings and decide the intervention goals. The targets were concerned with creating small groups of children based on their developmental play level (when possible), se-lecting appropriate toy for the groups (based on students’ play level) and learning techniques to initiate peer-to-peer interactions. At the same time, teachers were enrolled to 8-week vivo coaching sessions, with the researchers coaching the teachers to implement JASPER strategies to their students during the 15-minute play center rotation. Training was consisted of presenting intervention strategies for promoting social engagement, as well as comments and solutions for the teachers about issues that occurred as they performed the activities with their preschoolers. After the first 4 weeks of the intervention, in the remaining 1 month the teachers were asked to be less guiding and more responsive to the play and communication initiations of the children. One study (1) that came up from the current review investigates the possibility of back-ground music during play activities acting as a tool for encouraging preschoolers social behav-ior and increasing engagement and communication. The impact of background music was measured by estimating every student’s meaningful engagement while participating in struc-tured play. A wide range of centers were available for different activities, including circle area and large group section, furniture for organized work and free or structured play in areas rec-ognised by toy boxes and floor rugs. The intervention took place in the preschool’s typical routine, immediately after the students’ entry in the morning. Participants were able to choose and play from various of toys, such as books, kitchen utensils, blocks, play activities lasting no more than 30 minutes. Teachers and professionals were next to the students, playing with them and infrequently making comments about the students’ play. It was important their actions to not create social interaction directly but to support and maintain the play in the socially appro-priate levels, by talking and explaining the play of the other students. The study’s duration was 7 months and the observed play lasted approximately 15 minutes for both conditions. In the treatment setting, three kinds of background music were used, in order to observe changes and whether the outcomes were affected by the different types of music.

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Another study that emerged (6) examined the possibility of sung instructions, in com-parison to spoken instructions, causing higher levels of social and communication engagement in preschoolers with autism. The intervention lasted 3 months and included 18 sessions, with three play activities taking place. Every activity was performed in both sung and spoken settings and every session lasted approximately 4 minutes per condition. Sessions were ensured to be contextually and structurally similar, with only difference the way of presenting the instruc-tions. Every child participated in 18 sessions divided to 9 sung instructions and 9 spoken in-structions. The spoken and sung instructions were given to the participants by the therapist as “invitations”, with the aim of provoking them in responding in a socially acceptable way, while they were engaging in the play activities. The participants’ responses to the therapists’ “invita-tions” were grouped in “Performance”, “Social Gesture” and “Eye contact”. The intervention started with the therapist greeting the participant and/or showing available play materials, in order to cause an interaction. Then, any type of response was expected from the participant (verbal, nonverbal). Finally, if the participant’s response was socially appropriate, it would be encouraged and supported with clapping,

Next study from the results of this literature review (5) tested the effectiveness of a video modelling intervention and the utilization of the special interests of children with ASD, aiming in enhancing their social engagement with games and their peers. The ratio of the intervention was 1:2, with one child with ASD interacting with two typically developing students. Before the beginning of the experiment, during center time, the children with autism were asked to choose three areas from the available ones in the classroom. Based on the play skills and special interests of children with ASD and the preferences of the play partners, one intervention game was chosen for each group. The same intervention game was used in all four parts of the study, but in the “Video modelling intervention” part, children’s special characters were used.

The experiment started with the “Baseline”, where children were given the game with-out the special interests’ characters. The instructor initiated the game, but no further directions were given. The first phase lasted 10 minutes. The second part of the experiment “Video mod-elling intervention” begun with the special interests’ character appearing in front of the students. Then, instruction regarding the projection of the video on how to play this game was given and were requested to follow what they watched. When children did not engage, instructions were given. The intervention was completed, when students achieved 90% of the desired goals. “Maintenance” included the same games with the special character, without watching the video again. “Follow up” took place after one month, similar to the “Baseline”.

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The final article of this review (7) investigated the effectiveness of an intervention pro-gram that was consisted of both priming of social and more complex play using preferred toys in the context of creative dance activities among students with autism. Focus was the promotion of their social play engagement. Before the examination, teachers were asked to select the par-ticipants’ favourite toys. Then, participants had to pick one of them. The interventionists initi-ated a social play with the student using the preferred toy. This procedure was repeiniti-ated five days after the intervention at the follow up sessions.

Baseline lasted 20 minutes per day with children participating in their standard class-room routine, rotating and playing at the available play “zones” or areas. The selected toys were not present. The intervention started with a creative dance activity lasting 10 minutes and each day the actual dance activity differentiated. However, a specific format was followed. The in-terventionist played a hello song to begin the activity, followed by a quick warm-up movement activity. Then, dance activities started, that encouraged children to move throughout the school-room, leading to a closure activity accompanied by a slow tempo. The intervention was com-pleted with a goodbye activity, while objects were placed back. Children’s reaction, emotional status and level of participation affected the activity’s music tempo, beat and intensity each day. The creative dance activities were followed by setting the selected toys and materials in three different play areas and observed whether the participants played with them or not. The “follow up” part was completed 7 days after the intervention and kept on for approximately one month.

5.2.5.1 Interventionists

The second research question focuses on who can implement the interventions. Although all studies were implemented within the natural context of school, different adults participated in performing the interventions. The ASAP program (2) consisted of classroom-based educational teams (teacher and paraprofessional) with minimum knowledge on psychology, in comparison with one of the two JASPER studies (3), where staff and students with research training have participated. In the second JASPER study (4), classrooms teachers and aides were used as the primary interventionists, similarly with the ASAP study. Since, the ASAP program focuses not only on the promotion of preschoolers’ social interaction and participation in classrooms but on the reduction of educators’ exhaustion when teaching children with autism as well, both teachers’ training and children’s primary and secondary outcomes are in their interest.

Play interventions as a means to promote social engagement in preschoolers with autism. : A 2010-2020 Systematic Literature Review