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.  

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.