​Take a role in the play
 
Rather than stay on the sidelines as an appreciative observer or narrator of the play it’s important to take a direct role as you engage with your child. In a complementary role in simple pretend play (for example, if the child has just begun to pretend and use objects in expected ways such as using a brush to brush a doll’s hair or pretending to stir “soup” in a pot) you can ask to taste the “soup” the child is repeatedly stirring and, after tasting, ask her to pour some into your dish.  
 
As the child’s play begins to evolve and he begins to understand and take on more varied and complex themes, you can assume a range of roles such as a customer in a restaurant in which she is acting as a cook or server, a patient in the doctor’s office, a passenger in a plane he or she is piloting, or a complementary role in a favorite movie, story, book, or TV/video series. In your role you can take on a voice to distinguish your character from yourself or speak for and animate a stuffed animal or puppet character. You can take on more than one role in the play by, for example, pretending to be the mean stepmother and later taking the role of the Fairy Godmother as your child pretends to be Cinderella. In a pretend car race you can be both an audience member cheering on the child’s racecar and the announcer declaring the start of the race and the winner. Try to vary your voice as you play the different characters or roles. You can also make suggestions to thicken the plot (see next section) from within your role(s) or revert back to yourself and use a “stage whisper” to distinguish yourself from your character to provide support or make a suggestion. 
 
Thicken the plot
 
By gradually introducing new elements into play we support the child’s ability to think in a more complex and flexible way. Some examples: (1) After exploring the planet her spacecraft has landed on, add a new twist by pretending to examine a fuel gauge and announcing that it’s out of fuel; (2) Have your character ask for a ride on the train the child is repetitively pushing around the train track. Add details by asking if the train stops at “Whoville” (or wherever you choose) and if you can buy a ticket to travel there. 
 
In addition to supporting more complex and flexible thinking, thickening the plot is an important strategy to incorporate if play becomes repetitive or if the child has a tendency to engage in scripted play based on a memorized story or video script. Do join in with scripted play by commenting on the characters and actions. Some children are very sensitive to their partners’ attempts to steer scripted play in a different direction. I recommend very gradually offering new ideas that diverge from the script. These can be very slight divergences from the actions or ideas. Once the child becomes comfortable with these minor changes it may be increasingly possible to collaboratively shift between or elaborate on ideas in the play.  
 
Recognize and encourage emotional expression in play
 
For children to be able to effectively cope with and manage their feelings, especially children with autism and other developmental or behavioral challenges, they must be offered many opportunities to label, identify, and discuss emotions. Engaging in pretend play with children in which they play out emotional themes is critical to helping them feel comfortable with a full range of emotions. When an emotion, particularly an intense emotion such as anger or aggression, is expressed through words or play rather than the child directly acting it out or simply attempting to inhibit it, it is an enormous advance. Although at first it may not be apparent, allsymbolic play represents the child’s experience and emotion in the present moment whether he or she is feeding a baby doll (feelings of nurturance and dependence on others), making her zoo animals jump excitedly (pleasure and excitement), searching for hidden treasure (curiosity), has dressed up as a super hero with super-human powers (sense of power), or is having dinosaurs attack each other (aggression).
 
A full range of emotions includes anger and aggression, fears and anxieties, sadness, shame or embarrassment, rejection or loneliness, etc., positive emotional expression such as love, joy and happiness, or a sense of pride and competence, and themes such as nurturance and dependence, curiosity, and desire. When adult partners join in the child’s play and accept and encourage the emotions expressed, including anger and aggression, they help a child become more comfortable with expressing a full spectrum of emotions. In addition to accepting and encouraging the predominant emotions, partners may also gently suggest a theme that counters the child’s predominant emotions. For example for a child who engages in frequent repetitive angry/aggressive play with animals, dolls, or action figures we might have our character offer something helpful or nurturing such as a band aid or to “kiss the booboo”.  For the child who is uncomfortable expressing control or assertiveness we can use a big voice and have our character demand, “More pancakes now!” and encourage the child to have their character do likewise.
 
Tailor play to children’s individual differences
 
Children on the autism spectrum or with other developmental challenges have a range of individual differences that can significantly impact their social interactions and play.  These include motor planning difficulties, high or low muscle tone, auditory processing, visual-spatial processing, sensory processing difficulties (including under-reactivity and over-reactivity/sensitivity), distractibility, hyperactivity, etc. We can support interactions and play by playing to the child’s strengths and modifying and tailoring the way we interact with the child. I will provide a few examples. (For more extensive discussion see the recommended publications and Internet resources listed below).

• For the child who is under-reactive to sensory input and tends to be withdrawn we want to really ham it up in our play while for the child who is under-reactive and craves sensory-motor input combine pretend play with gross motor activities (for example, pretend to be on a pirate ship while bouncing on a trampoline or pretend an outdoor play structure with a climber and slide cis a space ship).
• For the child with auditory processing issues words need to be clear and lengthy monologues should be avoided. Use lots of animation as you act out pretend characters.
• The play of children with visual-spatial processing issues can be very fragmented as they move randomly from one idea or theme to another. They may have difficulty keeping track of and integrating objects and props into their play and can be helped by reintroducing the objects into their play. Children with these issues will also have difficulty sorting through and selecting objects from cluttered toy boxes or shelves. It can be helpful to sort out toys and props and assemble pretend play sets based on themes of interest to the child such as “fire station”, “cooking”, “baby care”, “the zoo”, “restaurant”, “farm”, etc. in plastic bins, cardboard boxes, or on shelves.

 
Recommended books for supporting the pretend play of children with autism spectrum disorder and other developmental challenges:
 
The Child with Special Needs: Encouraging Intellectual and Emotional Growth by Stanley Greenspan and Serena Wieder.
 
Engaging Autism: Using the Floortime Approach to Help Children Relate, Communicate, and Think by Stanley Greenspan and Serena Wieder.
 
Floortime Strategies to Promote Development in Children and Teens: A User’s Guide to the DIR®Model by Andrea Davis, Lahela Isaacson, and Michelle Harwell.
 

A question that comes up in my work with children is when and how to help a child engage in pretend play. Pretend play is an essential step in child development. Pretend play (and symbolic thinking more generally) underlies the ability to reflect on reality, imagine “what if”, and to think flexibly and is an essential step in child development. Understanding and using symbols including verbal language, reading decoding and comprehension, written expression, mathematics, the sciences, and the arts are built on this foundation. Participation in pretend play enables children to connect words and symbols to emotions and act less impulsively. A critical aspect of social development, perspective taking (also referred to as “theory of the mind”) which enables children to understand the world from another’s point of view, is supported when the child takes on the actions and roles of others in pretend play. 
 
Given the importance of pretend play for developmental growth there may be a question as to when to begin focusing on this type of play, particularly for a child with autism or other developmental disorder. If you’re regularly engaging your child in back and forth interactions and she’s warmly engaged with you, closing many circles of communication (i.e., responsive to your initiations), and initiates to you with gestures, vocalization, etc. she’s ready for pretend play. In this post (Part 1) I offer pointers to “get the ball rolling”. Part 2 will suggest ideas to further enrich and elaborate on play and address individual differences and concerns. 

1. Engage around what interests your child 

Engaging with children based on what interests them facilitates rich interaction and sustained engagement and these interactions offer the foundation for developmental growth. To learn what interests your child observe what he or she does in their spare moments, what fascinates them, what they love to do, and what they’re interested in in the moment and then look for opportunities to engage them around these interests. Do they love it when you play music at home or in the car, do they love nothing more than looking out the window to see all the cars and trucks that pass by, are they fascinated by airports, are they always in motion, or do they have a strong interest in sports stars and statistics? Acting out imaginary games of baseball or basketball may be the entrée to symbolic play for a boy or girl with a strong interest in sports and sports stars.  If a child loves dump trucks, play can focus on pretending to drive, back up, load and unload a toy dump truck.  A child who enjoys going with Dad to pick up food at the drive thru of a fast food restaurant is likely to enjoy enacting this activity.  Offer a pretend “mike” to a child who enjoys listening to music on YouTube, CDs, or the car radio.

 2.    Treat actions and objects symbolically

As we engage with children during their daily activities there are often opportunities to offer symbolic ideas by treating objects and actions symbolically. Here are examples: 

• Your child has finished drinking his milk or juice from a cup. You pick up the empty cup and pretend to drink from it (including sound effects of slurping). You say “Mm! That was delicious juice!”
• You’ve lifted up your child in your arms. You say “OK pilot, let’s take off” and move her around as she “flies to Florida to see Grandma”.
• Hand your child a “key” to open the front door of a dollhouse or to start the engine of a toy car he’s shown interest in.
• As your child is pushing a toy dump truck around on the floor have a toy figure ask if he can get a ride home.
• As your child crawls in and out of a play tunnel suggest that she’s exploring a cave and ask if she sees a bear in there.
• As a child is sliding down a sliding board talk about sliding down into the ocean and mention the sea creatures he may encounter (whale, shark, schools of fish, etc.) after he steps down. Ask what he sees once he’s gotten off the slide.
• As a child is banging pots together say, “I’m in the band too” and join in or you can start marching and say, “Let’s start a parade!”

 
3.  Offer toys and materials that support pretend play

• Pretend play toys include dolls, puppets, stuffed animals, action figures and toy figurines, play vehicles (cars, trucks, trains, airplane, bus, etc.), materials for pretend cooking and housekeeping, empty food containers, play sets for different themes (farm, zoo, fire station, etc.), etc. 
• Open-ended toys and materials including art materials such as crayons, markers, paints, modeling materials (play dough, clay), and blocks and construction toys can also be offered to encourage symbolic play and representational thinking. These open-ended materials are age-appropriate for supporting symbolic thinking in older children and teens. Older children and teens may also enjoy discussing the plots of books, movies, fictional TV series, etc. including possibilities for alternate endings. 
• Closed ended toys and materials. Closed ended toys are more helpful for promoting fine motor and perceptual skills and building attention than pretend play. These types of toys have a specific purpose and are generally used in a set way. These include puzzles, shape sorters, matching and memory games, mazes, manipulative/fine motor toys such as stringing beads, pegboards, etc.
• While pretend play toys and materials are helpful, don’t overlook the opportunities for pretend play/symbolic thinking using everyday materials  throughout the day including large motor play, outdoor play, and daily routines such as snack time, bath time, etc. as discussed in pointer #2 above.

 4.  Broaden the child’s range of emotionally meaningful experiences 

​Inspiration for pretend play is all around us and can emerge from a broad range of emotionally meaningful experiences such as visits to a zoo or aquarium, a fire station, an airport to see the planes take off and land, the beach, an animal shelter, etc., etc. Even routine trips to the supermarket or accompanying a parent to pick up pizza at a pizzeria can offer possibilities for imaginative play and enrichment of play. During the visit help your child notice various facets of the setting or experience and the roles of people. If possible take photos or make a video to talk about afterward. Also keep your eyes open to what is of interest to your child right in their own neighborhood such as the mail delivery person doing their rounds or workers repairing the road. For each child, among their experiences in the world around them, there will be ones that particularly “click” and inspire play.  

When I think about differences in ways of interacting with children, one defining factor that stands out to me is whether adults attempt to engage the child by insisting on compliance or by genuinely connecting with the child. This I believe is one of the key defining differences between different approaches to parenting and educational and treatment philosophies. What exactly do I mean by this? I offer examples below.

In my work I often focus on engaging children who are initially difficult to engage (often as a result of biologically based challenges such as motor, sensory, visual, and/or auditory processing difficulties). The child may be self-absorbed or withdrawn or focused on a particular activity or object (watching a Barney video, running around the kitchen island, lining up objects, opening and closing doors, picking pieces of yarn in the carpet, etc.) to the exclusion of engagement with the people in his or her life. As a DIR®/Floortime™ practitioner, I (and others with a developmental philosophy) approach this by seeking ways to connect with the child that follow his lead and are in sync with his unique ways of hearing, seeing, touching, smelling, and/or moving and that will not cause him to underreact or overreact and be overwhelmed and pull away. A practitioner with a behavioral philosophy approaches this from a different perspective, gaining compliance, often referred to as “gaining instructional control”. The focus is on having the child associate the parent or practitioner as a provider of reinforcers in order to gain compliance with directions or requests. As I explain below I see a focus on compliance as limiting and often counter-productive in interactions with children.

Opposing philosophies or approaches are also played out in everyday interactions with children in families and in school settings. In schools teachers adopt different methods of engaging children in learning and in guiding their behavior that are influenced by educational philosophies (which may be their own or that of the educational program or school) and/or personal and professional history and experiences. Some teachers, schools, and programs focus on things like “running a tight ship”, children following the directions and completing the assigned work, checking off goals and objectives, or higher scores on standardized tests rather than deeply engaging learners in content, considering different points of view, posing questions, making sense of the ideas or concepts, problem-solving, divergent thinking and creativity, and a love of learning. The latter is often referred to as "engaged learning". The teacher whose focus is on engaging learners is also a teacher who values connection and forges genuine and joyful learning relationships with children. A narrow focus on compliance limits opportunities to genuinely connect with children and also limits children’s learning horizons.

When it comes to guiding children’s behavior in everyday situations like needing a child to brush their teeth; put on their coat, hat, and mittens to go outside; or follow the rules in the school lunchroom parents and teachers can choose between demanding compliance or supporting their child’s cooperation through connection. For example, a parent who connects with their child might engage with their child over choosing toys or different types of bubble bath for the bathtub instead of demanding compliance with the routine, using threats when the child refuses or fails to comply, or resorting to rewards or bribery. Not only is the connection approach likely to be more successful in facilitating the child’s cooperation, the very interactions between the parent and child to get ready for the bath, choose tub toys or bubble bath, run the bath, get dried and dressed for bed offer countless opportunities for learning. As parent and child connect and engage in this bath time routine the parent is supporting the child’s abilities to read and respond to the emotional cues of others, engage in long chains of back and forth interaction, modulate emotions, problem solve, engage in imaginative play, etc.! Likewise in a classroom the teacher whose focus is on connection rather than compliance, directly involves the children in discussions and formulation of classroom rules and uses problems that arise between children or between a child and adult as opportunities for supporting social problem-solving as well as social skills and higher levels of reasoning and thinking. These connection-focused interactions also build the foundations for self-regulation (involving the ability to plan, set goals, regulate emotions, inhibit impulses, delay gratification, independently problem-solve) a critical underlying foundation for development and learning.

Over-reliance on demanding compliance can be counter-productive in multiple ways. Over time, excessive, and especially, coercive demands for compliance are detrimental to the parent-child relationship. Often the result is exacerbation of a difficult temperament and problematic child behavior as well as negative interactions between parent and child. Demanding compliance can also undermine children’s formation of self-concept and self-identity, self-esteem, development of autonomy, and initiative taking. This is problematic for all children but even more so for children with developmental disabilities who are at much higher risk for developing learned helplessness and passivity. In the broader picture, as discussed above, emphasis on compliance instead of connection undermines the development of self-regulation and healthy foundations for relating, communicating, and thinking.

While I recognize the use of reinforcers, a schedule of reinforcement, or a reward system is an improvement over simply demanding compliance, making threats, using punishment, and coercive or negative interactions between children and adults and can see a limited place for this in some situations, support for a philosophy that embraces connection is a far better long-term alternative. A focus on reinforcers and simply changing a behavior in order to address problem behaviors such as aggression, non-compliance, tantrums, moodiness, impulsivity, etc. does not in and of itself build the foundations for self-regulation. Self-regulation enables children to manage their emotions, understand what’s appropriate and inappropriate, and respect the needs of others. Compliance-based philosophies when used in classroom settings can also undermine academic and pre-academic learning by limiting children’s potential for higher level, creative thinking and in-depth learning within a subject or topic. Parents, teachers, and therapists, who embrace connection over compliance, are best able to provide the vital opportunities for building healthy foundations for development, learning, and relationships.

 

Family-centered practice is considered the “gold standard” of practice for children with developmental disabilities and their families in health care, education, mental health, and social service systems and the relevant disciplines that provide services within these systems. It involves not simply collaborating with families but collaborating with families in ways that empower them in their role as decision maker. Allen & Petr (1998) identify among the core elements of family-centered practice “informed choice”. The element of choice is a core concept that is widely accepted in conceptualizations of family-centered practice.

Barry Prizant (2008) summarizes the key elements of authentic family-centered practice:

"Family-centered practice has as its primary goal, empowering families with the knowledge and skills to make the best choices for their child and for the family. In family-centered practice, professionals collaborate with families in decision-making about specific goals and objectives, as well as educational/treatment approaches. Parents are respected as experts regarding their child, and professionals consider each family's unique strengths and needs, as well as its cultural and religious values."

There are a number of factors families of children with autism spectrum disorders (ASD) should consider when selecting treatment options for their child. Among those I believe are particularly important for families to weigh are the following: (a) the goals or intents of the approach and whether those goals match the long-term and short-term needs of the child and family; (b) whether the philosophy of the approach respects and honors children’s individual differences, interests, and passions and families' culture and beliefs; (c) if the focus is on supporting and enhancing the child’s current capabilities and facilitating growth rather than changing the child in a fundamental way; (d) whether the approach is likely to support and strengthen the family's relationship with the child or if it could be counterproductive to this; (e) whether any methods that might be used with the child could potentially be aversive; and (f) if the approach is fully attuned with presuming competence and respecting the child's neurodiversity. Treatment approaches, or for that matter, providers, vary considerably in meeting these criteria. Thus, it’s critical that parents are able to access complete information on treatment approaches and it’s equally important that multiple treatment/intervention options are available to children and families. It's  also important to note that children with ASD often have needs that may require multiple therapies and treatment modalities and that needs change over time as the child develops. Even if a treatment approach has been helpful at one stage of development new or additional areas of need may emerge for which supplementary or alternative approaches are necessary. When information about potential options is withheld, incomplete information is provided, or information is provided in a biased manner, or agencies, organizations, or systems seek to limit the treatment options available this represents neither individualized intervention nor family-centered practice.

Practices of professionals, organizations, and service systems are relatively easy to categorize as to their family-centeredness. When it comes to the provision of services for children with ASD we see the following practices all too frequently and in many states and locales in the US these are the prevalent practices:

• One size fits all service system that offers no funding or access to real intervention choices (e.g., developmental approaches as well as behavioral, range of therapies including music, art, dance, etc. as well as OT, speech, PT).
  

• Professionals or agency administrators who cannot see beyond their own paradigm of practice and therefore limit the information or options discussed with parents. Whether motivated by sincere belief in a particular philosophy, the convenience of referring to a limited group of service providers, or financial factors this cannot be regarded as informed choice.
  

• Professionals who make a standard recommendation for treatment (e.g., “40 hours of ABA”) without ever questioning the “standard”, informing themselves about the research that supports their recommendation, seeking the actual lived experiences of individuals who have received the prescribed treatment, or fully understanding the implications of children’s individual differences and needs and families’ preferences and choices for selecting among treatment options.
  

• State service systems that build services around the treatment approaches favored or practiced by some practitioners while excluding or creating a firewall around other methods or models. This situation continues to be perpetuated even when newer or emerging research indicates potential benefit to children from the “out” methods thus depriving children and their families of the opportunity to benefit from these treatment approaches. In some instances the barriers created to prevent families from being informed of and accessing other methods not only exclude the “out” practitioners but financially benefit the “in” practitioners. Often this situation is further maintained by overly restrictive definitions of evidence-based practice which have been criticized in multiple disciplines (e.g., Biesta, 2007; Prizant, 2011; Rycroft-Malone et al., 2004).
  

The practices described above clearly do not represent family-centered practice. I have also observed initiatives and efforts around the US that do provide real options to families and children with ASD and other developmental disabilities. Examples include providing a pool of flexible funding which parents can directly access to pay for services of their choice such as consultations, evaluations, treatment, or supports; incorporating treatment options (e.g., DIR/Floortime, SCERTS, TEACCH) into children’s IEPs or IFSPs, and ASD insurance legislation that allows insurance payment for a range of treatment options beyond ABA services. Policymakers embracing family-centered practice and informed choice should also adopt policies that support training for practitioners in evidence-based intervention approaches and capacity building to enable schools and programs to provide multiple intervention approaches. This is particularly crucial for ensuring equal access of underserved and rural communities. I call upon all professionals, policymakers, agencies, and service systems to fully embrace family-centered practice and create greater flexibility and access to a range of treatment and support options for all families of children with ASD and other developmental disabilities.

Allen, R. I., & Petr, C. G. (1998). Rethinking family-centered practice. American Journal of Orthopsychiatry, 68(1), 4-15.

Biesta, G. (2007). Why “what works” won’t work: Evidence-based practice and the democratic deficit in educational research. Educational Theory, 57(1), 1-22.

Prizant, B. (2008). Treatment options and parent choice: An individualized approach to intervention. Autism Spectrum Quarterly, 4, 34-37.

Prizant, B. (2011). The use and misuse of evidence-based practice: Implications for persons with ASD. Autism Spectrum Quarterly, 15, 43-49.

Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practice. Journal of Advanced Nursing, 47(1), 81-90.