A Longitudinal Study of Pretend Play in Autism

Abstract This study describes a longitudinal design

(following subjects described in Rutherford & Rogers

[2003, Journal of Autism and Developmental Disorder,

33, 289–302]) to test for predictors of pretend play

competence in a group of children with autism. We

tested the hypothesis that developmental change in

pretend play performance can be predicted by earlier

measures of either executive function, intersubjectivity,

imitation, or general development. Participants at the

time of follow-up testing were 28 children with autistic

disorder (mean chronological age (CA) 57.6 months),

18 children with other developmental disorders (mean

CA 59.0 months), and 27 typically developing children

(mean CA 30.1 months). Children with autism were

profoundly delayed given both competence (prompted)

measures as well as performance (spontaneous) mea-

sures. Joint attention at time 1 strongly and uniquely

predicted pretend play development.

Keywords Autism Æ Pretend play ÆLongitudinal study

Introduction

Autism is a disorder that affects development of

reciprocal social relations, communicative ability, and

flexible, appropriate use of objects beginning in the

first three years of life (DSM-IV). Engagement in

pretend play is one of the areas of development most

profoundly affected by autism, and a large number of

studies of pretend play in autism have been published

over the past two decades, with the consistent finding

that children with autism show decreased frequency,

complexity, and novelty of spontaneous pretend play

behavior. Pretend play deficits are so widely recog-

nized in autism that a failure to use toys symbolically is

an item on many diagnostic systems for autism (e.g. the

ADOS; Lord et al., 2000 and the ADI; Lord, Rutter, &

LeCouteur, 1994).

Because of its primacy as a symptom of autism,

theories that attempt to explain the nature of the

cognitive impairments in autism need to account for

the problems with pretend play. However, few theories

have actually tested empirically their accounts for the

deficiency in pretend play in autism. In addition, the

actual developmental acquisition of pretend play skills

over time has never been examined. There have been

relatively few longitudinal studies involving children

with autism, generally focused on the stability of the

diagnosis, the stability of the severity of symptoms, or

prediction of long-term outcomes (Cantwell, Baker,

Rutter, & Mawhood, 1989; Chung, Luk, & Lee, 1990;

DeMyer et al., 1973; Eisenberg, 1956; Gillberg &

Steffenburg, 1987; Kanner, 1971, 1992; Lord & Scho-

pler, 1989; Lotter, 1978; Venter, Lord, & Schopler,

1992). However, longitudinal approaches allow for the

examination of causal influences on developmental

M. D. Rutherford (&)Department of Psychology, Neuroscience and Behaviour,McMaster University, 1280 Main Street West, Hamilton,ON, CanadaL8S 4K1e-mail: rutherm@mcmaster.ca

G. S. Young Æ S. J. RogersThe M.I.N.D. Institute, University of California Davis,Sacramento, CA, USA

S. HepburnDepartment of Psychiatry, University of Colorado HealthSciences Center, Denver, CO, USA

J Autism Dev Disord (2007) 37:1024–1039

DOI 10.1007/s10803-006-0240-9

123

ORIGINAL PAPER

A Longitudinal Study of Pretend Play in Autism

M. D. Rutherford Æ Gregory S. Young ÆSusan Hepburn Æ Sally J. Rogers

Published online: 5 December 2006� Springer Science+Business Media, LLC 2006

outcomes (Dawson, Toth, Abbott, Osterling, Munson,

Estes, & Liaw, 2004).

The present study was designed to accomplish sev-

eral goals: (1) to compare competing theories con-

cerning the cause of the pretend play deficit in autism,

(2) to examine the specificity of the pretend play

problems by comparing sensorimotor to pretend

play development and (3) to examine the questions of

delay versus difference and the question of compe-

tence versus performance, of the developmental

aspects of pretend play through the use of a longitu-

dinal design and multiple, carefully matched compari-

son groups. By studying atypical development, in this

case development in autism, we hope to learn more

about autism and more about typical development.

This study allows us to selectively test for develop-

mental relationships in cognitive skills that, although

not measurable in typical development, nonetheless

informs us about typical development.

Pretend Play

Play might be the predominant waking activity of

typically developing children (Sutton-Smith, 1976) and

typically developing children develop play skills with-

out explicit instruction (Garvey, 1991; Moyles, 1994).

Here we will define play as the purposeful manipulation

of objects in which exploration and practice of effects

appear to be the child’s goals. Piaget (1952) made a

distinction between sensorimotor play, involving object

manipulation as a means for practice and mastery of

action schemas, and symbolic, or pretend play, which

involved the use of actions on objects to represent real

life or imagined objects, characters, and actions. Piaget

suggested that pretend play provided the child an

opportunity to practice and understand the events

occurring in his or her life and in the child’s social

world. Pretend play generally appears by the age of

18 months and becomes more and more elaborate over

the preschool years (McCune-Nicolich, 1981).

The earliest examples of pretending often include

conventional acts on real, realistic, or miniature objects

outside of typical contexts, like ‘‘drinking’’ from an

empty cup, or rolling a toy car across the floor and

making engine noises. While this kind of play repre-

sents an early stage of pretend play development,

previous autism research has typically categorized this

kind of play as ‘‘functional’’ rather than ‘‘pretend’’

(Baron-Cohen, 1987; Ungerer & Sigman, 1981).

Functional play is theoretically separated from more

sophisticated play because a miniature replica may be

perceived as a small but real object and does not

clearly indicate that the child is using the object to

symbolize something else (Jarrold, Boucher, & Smith,

1994; Malone & Langone, 1998). Pretend play has been

defined in the developmental literature outside of the

autism literature as simulative or non-literal play (Fein,

1981) or acting as if something is the case when it is

not. For our purposes in this project, we have followed

these latter traditions, classifying as pretend play object

substitution, (the child pretends that some object

stands for another object) attribution of absent prop-

erties, pretending that an imaginary object is present,

and the attribution of animacy and agency to a doll or

other toy (McCune-Nicolich, 1981) without using a

separate category for functional play.

Pretend Play in Children with Autism

It is a well-replicated finding that children with autism

show reduced frequency, complexity, novelty and

spontaneity in pretend play compared to both children

with other kinds of delays and to typically developing

children (Baron-Cohen, 1987; Bernabei, Camaioni, &

Levi, 1999; Doherty & Rosenfeld, 1984; Gould, 1986;

Riguet, Taylor, Benaroya, & Klein, 1981; Ungerer &

Sigman, 1981; Wing, Gould, Yeates, & Brierley, 1977).

In 1975, Ricks and Wing provided the first review of

the play literature in autism and concluded that the

central problem in autism was a difficulty in general

symbolic capacity, affecting language, gesture, and

pretend play. In the first major research paper that

directly examined pretend play in autism, Wing (Wing

et al., 1977) reported decreased frequency of sponta-

neous pretend play in children with autism. In addition,

their pretend play was repetitive and stereotypic

compared to that of children of similar mental ages.

Sigman and Ungerer (Sigman & Ungerer, 1984) and

colleagues (Mundy, Sigman, Ungerer, & Sherman,

1986) reported autism-specific deficits in preschoolers

with autism in three related areas: frequency of spon-

taneous pretend play acts, frequency and complexity

of symbolic sequences, and frequency of different

symbolic acts, produced spontaneously and also in

response to an adult play model. Similar findings have

also been reported from studies of older children when

spontaneous pretend play has been examined (Baron-

Cohen, 1987).

Intersubjective Development and Pretend Play

While the initial interpretation of the pretend play

findings in autism focused on a general difficulty with

symbolization, a very influential paper by Alan Leslie in

1987 (Leslie, 1987) suggested that pretend play required

the same type of cognitive meta-representational

J Autism Dev Disord (2007) 37:1024–1039 1025

123

capacity that understanding other minds requires.

Understanding of other minds or ‘‘Theory of mind’’ is

thought to involve the capacity to understand another’s

mental states and predict behavior based on an appre-

ciation of these mental states (Astington, Harris, &

Olson, 1988; Baron-Cohen, Leslie, & Frith, 1985;

Wimmer & Perner, 1983). Theory of mind (ToM)

theorists have suggested that this capacity develops from

the understanding of other people as subjective beings,

with their own experiences and perspectives. This

intersubjective understanding begins to develop in the

latter half of the first year, as seen in the use of social

referencing, JA behaviors, and intentional communica-

tion to coordinate attention with another and share

experiences (Tomasello & Rakoczy, 2003).

Both theory of mind capacity and pretend play are

specifically impaired in autism, and Leslie has sug-

gested that both of these skills required the capacity to

represent another’s representations, a capacity that he

called metarepresentation. Leslie described the meta-

representational challenge as follows: in pretend play

the child needs to simultaneously hold two represen-

tations in mind, the primary, or veridical representa-

tion and the newly assigned pretend identity (termed

meta-representation), in order to either produce or

understand others’ pretend play.

While this view of pretend play is not universally

accepted among cognitive psychologists, the theoretical

links among pretend play, theory of mind, and JA

behavior have some empirical support in normal

development (Charman et al., 2003) and are further

strengthened by the repeated findings of autism-

specific deficits in all three areas (Volkmar, Lord, Bai-

ley, Schultz, & Klin, 2004). For these reasons, one

purpose of this study was to test the affect of inter-

subjective development on pretend play development.

There is little disagreement in the field that JA

behaviors reflect young children’s awareness of some

‘‘mental’’ processes in others, particularly others’

attention, intention, and affect. Joint Attention (JA) is

the triadic coordination of attention between the child,

another person, and an object or event. Children with

autism are known to be impaired in the production and

comprehension of JA gestures (Curcio, 1978; Ricks &

Wing, 1975), and in their ability to follow or monitor

someone’s gaze (Leekam, Hunnisett, & Moore, 1998).

JA behaviors may be a good measure of the develop-

ment of a precursor of ToM, and it has been argued

that JA behaviors directly reflect a capacity for meta-

representation (Baron-Cohen, 1989), are a precursor of

the theory of mind ability (Rochat & Stiano, 1999) and

are thus markers of the developing ToM. Thus, JA is

the most appropriate measure of ‘‘mental’’ under-

standing in children as young as those in our study.

Executive Function and Pretend Play in Autism

A series of studies have challenged the view that chil-

dren with autism are specifically impaired in the ability

to create pretend play representations (Lewis & Bou-

cher, 1988; Morgan, Maybery, & Durkin, 2003) These

and additional studies using other paradigms have

revealed similar findings: that children with autism

recognize, remember, select and produce symbolically

transformed scenes and props when an adult scaffolds

the situation, leaving vulnerable the intersubjective

account of pretend play development. These findings

provided the first real challenge to the metarepresen-

tational account of the pretend play deficit in autism.

Jarrold and colleagues (Jarrold, Boucher, & Smith,

1996) suggested that this was better understood as a

problem of generating the play ideas rather than a

difficulty with understanding the underlying represen-

tation. Generativity is one of the executive functions,

others of which include the ability to plan ahead in a

sequence of actions, the formulation and initiation of

goal directed behavior, inhibitory control, working

memory and the ability to generate novel behaviors,

and flexible control of attentional processes (Penning-

ton et al., 1997). Pretend play requires inhibition of the

real world interpretations, generativity of new ideas,

and shifting attention from one interpretation of toys

to another. Children with autism show deficits on a

variety of EF tasks (Hughes & Russell, 1993; McEvoy,

Roger, & Pennington, 1993; Ozonoff & McEvoy, 1994;

Ozonoff, Pennington, & Roger, 1991), including set

shift tasks and planning tasks, such as the Tower of

London task (Hughes, Russell, & Robbins, 1994), the

Wisconsin Card Sort task, and the Windows task

(Russell, Mauthner, Sharpe, & Tidswell, 1991). Thus, a

difficulty with one of the executive functions provides

an alternative theory to account for competence–

performance differences in pretend play.

A Social Learning Interpretation of Pretend

Play Problems in Autism

There is one further explanatory theory that has been

suggested, this one based on the lack of dyadic

engagement and social learning that children with

autism experience through imitating and being scaf-

folded more experienced play partners. Imitative or

observational learning has not been thought to depend

on JA or other triadic processes, though it may

1026 J Autism Dev Disord (2007) 37:1024–1039

123

contribute to them (Rogers and Pennington, 1991:

Rogers et al, 2003). While developmentalists tend to

think of play as developing through cognitive matura-

tion, several authors have emphasized the importance

of imitative, or observational learning in the develop-

ment of pretend play. Piaget theorized that symbolic

play developed from imitation of the social world, as

deferred imitation (Piaget, 1952). Note that the social

learning view implicitly weighs the role of both

immediate and deferred imitation heavily, as a crucial

vehicle for social learning. Therefore, we use a

measure of imitation as a marker of social learning in

this age group.

General Cognitive Maturity as a Predictor

of Pretend Play

Finally, it is possible that pretend play develops in an

individual as that individual matures cognitively. This

view is widely encouraged, sometimes explicitly,

sometimes implicitly. Developmentalists tend to think

of play as developing through cognitive maturation.

Therefore, we include a measure of mental age (MA)

as a predictor variable.

Using Longitudinal Studies to Test Developmental

Theories

Each of the above theories suggests a different set of

foundational skills as necessary for the development

of pretend play in early childhood, and a longitudinal

design could help to test these different models.

Longitudinal studies of typical development have

consistently found a relationships between pretend

play and language development (Haight & Miller,

1992; McCune-Nicolich, 1981; Russ, Robins, &

Christiano, 1999). Longitudinal studies have also

documented relationships between play patterns of

social partners and development of pretend play in

typical children (McCune, Dipane, Fireoved, &

Fleck, 1994), providing possible support for a social

learning view of pretend play.

There has been very little longitudinal work examining

pretend play in autism. Marian Sigman and Ruskin

(Sigman, 1998; Sigman & Ruskin, 1999) published a large

and comprehensive study of 70 children with autism, 93

with Downs, 59 with other developmental delays, and 108

typical children. These children were initially tested be-

tween 1 and 5 years of age and tested again 8–12 years

later. Although she used pretend play measures as early

predictors, she did not report follow-up measures of

pretend play. Rather, she was interested in how early

pretend play measures related to later verbal and social

capacities, and found that an early measure of pretend

play was a significant predictor of later language.

While several models may explain the pretend play

deficit in autism, only a few papers have attempted to

test these models. Morgan et al (2003) tested the

explanatory power of the central coherence hypothesis

to account for pretend play deficits and found that

pretend play was completely independent of central

coherence measures in both children with autism and

those with other delays. In an earlier paper, we began

to test these theoretical models (Rutherford & Rogers,

2003). We examined the relationships between pretend

play performance, general developmental maturity, JA

as a marker of intersubjectivity, and two executive

functions: generativity and inhibition. For the entire

group of children, both executive function tasks were

strongly associated with pretend play, but not with

sensorimotor play. In the present study, we use a lon-

gitudinal design to test these theoretical accounts of

the pretend play deficit in autism.

The Current Study

The present study was designed to test these seven

hypotheses:

1. Pretend play in autism is dependent upon general

cognitive maturity (MA) and general symbolic

capacity. Early developmental rates measured as

MA will predict pretend play maturity at time 2.

2. Pretend play is dependent upon executive perfor-

mance. Early measures of generativity and cognitive

flexibility will predict maturity of pretend play at

time 2.

3. Pretend play depends on understanding others’

mental representations. Given that pretend play

emerges during the first two years of life, JA

behaviors are the best measure of developing

awareness of other’s ‘‘mental’’ processes.

4. Pretend play is dependent upon social learning

experiences as well as cognitive maturity. Ability

to imitate others is the main vehicle for social

learning and should moderate development of

pretend play skills in autism.

5. Children with autism will demonstrate a qualita-

tively different pattern of pretend play development

compared to typically developing children or those

with general developmental delays—demonstrating

a deviant pattern of development rather than simply

a delay.

J Autism Dev Disord (2007) 37:1024–1039 1027

123

6. Children with autism will demonstrate more

impairment in spontaneous performance of pre-

tend play than in scaffolded situations, supporting

the competence/performance hypotheses of pre-

tend play in autism.

7. Pretend play is uniquely affected in autism. Sen-

sorimotor play is unaffected by autism and reflects

developmental maturity.

Methods

Participants

The participants were 28 children with autistic disorder

(AD), 18 children with other developmental disorders

(DD), and 27 typically developing children all matched

on overall MA at both time periods. Children in the two

clinical groups were seen twice over a 24-month period.

In order to maintain developmental matching of all

groups, the typically developing children were seen

twice within a 12-month period. The average chrono-

logical ages (CA) of these children at time 1 were

33.9 months for the children with autism, 34.8 months

for the children with other developmental disorders,

and 19.5 for the typically developing children. The

average CA at time 2 were 57.6 months, 59.0 months,

and 30.1 months respectively (see Table 1).

The children with autism and other developmental

disorders were recruited from various health and early

education agencies. The typically developing children

were recruited from pediatrician’s offices and through

a large university developmental subject pool. The

children with autism were free from any other medical

condition, had no visual or hearing impairment, had

been diagnosed with autism by an outside agency,

received current clinical diagnoses of autism, and met

criteria for autism on at least two of three diagnostic

systems: DSM-IV, ADI-R and ADOS-G.

The children in the DD group all had normal vision

and hearing or vision corrected to within the normal

range, had unimpaired hand use, and were mobile.

None was considered by any clinician, past or present,

to have symptoms of autism. No one in the DD group

met criteria for autism on the DSM-IV, one met

criteria for autism on the ADOS-G, and one met cri-

teria for autism on the ADI-R. These children were

kept in the sample because clinical assessment did not

suggest autism, and because any bias introduced would

be conservative. The diagnoses for these 18 children

included 7 children with Down Syndrome and 11

children with mixed etiology developmental disorders.

There were 27 typically developing children who

continued to time 2 testing. None of these children met

ADOS-G, ADI-R or DSM-IV criteria for autism or

PDD. None of them had other psychiatric or devel-

opmental diagnoses.

Measures

Autism Diagnostic Interview—Revised (Lord et al.,

1994)

The ADI-R is a structured, standardized parent inter-

view developed to assess the presence and severity of

symptoms of autism in early childhood across the three

main symptom areas in autism. Raters in this project

were reliable to 85% or better item agreement on three

consecutive administrations using the full range of

scores (0–3) rather than the truncated scoring usually

used (0–2). Reliability was checked on 20% of partic-

ipants and was at or above 85%.

Autism Diagnostic Observation Schedule—Generic

(Lord et al., 2000)

The ADOS-G is a semi-structured standardized inter-

view using developmentally appropriate social and toy-

based interactions in a 30- to 45-min interview to elicit

symptoms of autism in four main areas: social inter-

action, communication, play, and repetitive, restrictive

behaviors. Dr. Lord trained two of the raters in the

present study to reliability on the ADOS-G; the other

raters in the lab were trained to reliability of 85% or

better item agreement on three consecutive adminis-

trations using the full range of scores (0–3). This was

measured on 20% of participants.

Mullen Scales of Early Learning—(Mullen, 1989)

The MSEL is a standardized developmental test for

children ages 3 months to 60 months consisting of five

subscales: gross motor, fine motor, visual reception,

expressive language, and receptive language. The

MSEL was administered to all subjects according to

standard instructions by raters with advanced degrees

trained in assessing young children with autism and

other developmental disorders. Reinforcers were used

at times to reward cooperation and attention.

Abridged Early Social Communication Scales (ESCS;

Mundy, Hogan, & Doehring, 1996)

The ESCS involves a 20-min semi-structured toy-based

interaction between examiner and young child that is

1028 J Autism Dev Disord (2007) 37:1024–1039

123

designed to elicit a sample of a child’s non-verbal

communicative behaviors across several communica-

tive functions. Inter-rater reliability was initially

established at 85% and then maintained throughout

the project by having two raters code 20% of all tapes.

All JA measures in this study were taken from the

ESCS. We calculated overall JA scores by converting

both Initiating Joint Attention (IJA) and Responding

To Joint Attention (RJA) scores to Z-scores, and then

taking the average of these two measures for each

subject, yielding a normalized JA score for each

subject. Before this transformation, IJA and RJA were

significantly correlated (r = .30, P = .01). We used this

overall JA score as our index of awareness of others’

mental processes.

Pretend Play Frequency Counts

and Developmental Measures

There is a theoretically important difference between

competence and performance of pretend play, but to

date most work in this area has focused on perfor-

mance rather than competence. In most of the studies

on pretend play in autism, data have involved

frequency counts from videotape, a good index of

performance, but not suitable as a measure of com-

petence. The particular frequency variables that are

gathered and analyzed have significance for the inter-

pretation of group differences. As the studies from

Sigman’s lab have illustrated, examining total number

of play acts in a category can give quite a different

picture than examining number of novel play acts, or

maturity of play acts. Qualitative differences may be

missed when more fine-grained aspects of the play are

not considered. There are some methodological

options for assessing competence, or maturity of play

(Fewell & Rich, 1987) and this approach was used in

this study.

The Fewell Play Scale, 5th edition (Fewell & Rich,

1987) was administered to all subjects by trained raters.

This scale involves a semi-structured play interview

designed to assess play maturity in children

5–30 months of age. A set of toys is placed on the table

and the experimenter says ‘‘What can you do with

these toys?’’ or ‘‘Here are some things that you can

play with.’’ If the child does not play spontaneously,

the experimenter prompts the child by either modeling

the play behavior, or giving specific instructions. The

exact verbal prompt or model action is specified for

each item. Items are ordered from easiest (targeted to

2- to 4-month-olds) to hardest (targeted to 27- to

30-month-olds), and the test is terminated once both

the basal level (three consecutive passes) and the

ceiling (three consecutive failures) are found.

Table 1 Chronological ageand Mullens overall MA

CA (months) VMA (months) NVMA (months) Overall MA (months)

Time 1Autistic disorder: n = 28

Mean 33.65 16.50 23.7 20.35SD 3.67 6.8 6.17 6.35Range 26–41 5–33 12.5–43.5 11.5–41.75

Developmental disabilities: n = 18Mean 35 20.36 23.41 21.75SD 7.21 6.5 6.58 6.2Range 24–47 11–31 16–35 14.25–33

Typically developing: n = 27Mean 19.67 23.83 23.41 21.26SD 4.77 7.13 6.58 4.56Range 12–35 11.5–42.5 16–35 14–28.5

Time 2Autistic disorder: n = 28

Mean 57.6 29.21 38.21 37.2SD 3.89 13.70 13.28 12.5Range 48–65 8–51.5 14–62.5 12.25–56.25

Developmental disabilities: n = 18Mean 59.0 34.36 36.36 35.64SD 7.6 11.93 10.61 10.98Range 47–71 10.5–62 16.5–51.5 13.5–56.75

Typically developing: n = 27Mean 30.1 39.5 35.9 38.0SD 4.1 6.68 5.0 5.2Range 25–38 24.5–54.5 25.5–46.5 25–45.5

J Autism Dev Disord (2007) 37:1024–1039 1029

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The Fewell measure gives a child full credit for

performing a pretend play act even once because it

demonstrates that the child has that ability. Our

measure provided an opportunity for both spontaneous

and scaffolded play, further lending each child an

opportunity to demonstrate his or her competence. If

the child did not produce a specific play act sponta-

neously, the adult prompted it first by a verbal prompt,

then by modeling, then finally with the verbal prompt

and modeling combined. This use of controlled task

difficulty and carefully specified and graded prompts

gave each child every opportunity to exhibit his or her

level of competence, and to largely bypass confounds

such as motivation and generativity deficits seen in

studies that focus on frequency counts. The order in

which our subjects passed the items was highly corre-

lated with the canonical order of the Fewell Play Scale,

supporting the developmental ordering of the scale.

For the purposes of this project, the total scores were

divided into pretend play scores and sensorimotor play

scores. The pretend play scores included all items

involving acts with a doll as agent, and all items involving

the use of a prop as if it were another object (Rutherford

& Rogers, 2003). In calculating scaffolded pretend play

scores, a child was awarded 4 points for completing the

item spontaneously, three points for completing it with a

verbal prompt, two points for completing it after it was

modeled, one point for completing it after both a verbal

prompt and modeling, and no points if the item was not

completed. Reliability was high; Cronbach’s a was .79

calculated on 100% of subjects.

Twenty-one of the items from the original play scale

made up in the sensorimotor play scale. Scores were

calculated in the same way as for the pretend play scale.

Reliability on this scale was also high; Cronbach’s a was

.80 in this study calculated from 100% of subjects.

Executive Function Measure: Spatial Reversal Task

This task was designed to assess the child’s ability to

change search strategy when the spatial location of a

reward had changed, based on a paradigm developed

by Kaufman and colleagues (Kaufman, Leckman, &

Ort, 1989). In the first trial, two opaque cups were

inverted on a table behind a screen, and out of view of

the child. A reward (a snack or toy) was placed under

each cup. The screen was removed and the child was

allowed to search for the reward by looking under only

one cup. In the next trial, the reward was placed only

under the cup that the child looked under in the first

trial. Once the child has achieved four consecutive

correct searches, the reward was hidden under the

other cup. The location of the toy was reversed

following every fourth consecutive successful trial for

23 total trials.

The number of correct searches was recorded

(excluding the first trial) as were the number of

perseverative responses. A perseverative response was

a search that repeats an immediately preceding incor-

rect search. The scores analyzed in this study were the

number of correct searches minus the number of

perseverative responses.

Imitation. The imitation battery was developed by

one of the authors (S.R.). The initial battery consisted

of 16 tasks. Seven items were eliminated prior to

analyses due to violations of assumptions of normality;

so nine items were used (three manual acts, three non-

conventional actions on objects, and three oral-facial

movements). (See Rogers et al, 2003 for imitation

items.) The test battery was split in half and adminis-

tered on two separate days using a counterbalanced,

randomized order of items. Items were administered at

a table, with the child facing the adult. A specific

administration procedure was employed throughout

imitation trials based on (Meltzoff and Moore, 1977).

With the child looking directly at the adult, the exam-

iner said ‘‘(Name), do this’’ and repeated the action

three times rapidly in a burst of three actions each (thus

demonstrating nine rapid repetitions of the action).

The child was rewarded for any attempt with social,

and sometimes tangible, rewards. The first spontaneous

imitation and the best imitation were scored and all

coding was done from videotape. Examination of first

and best performance scores revealed no significant

differences; therefore, first scores were used through-

out the analyses. Scoring criteria for accuracy of each

item were established based on the number of errors

involved in the child’s performance, with 0 reflecting no

action at all, 1 reflecting a movement that appeared

unrelated to the target movement, and higher scores

reflecting fewer errors in the production. Errors con-

sisted of inaccuracies like bimanual-unimanual substi-

tutions, location of contact point on the body, and

inaccurate limb positions. For the analysis, the scores of

1’s were converted to 0’s, so that only imitative re-

sponses received scores. Inter-rater reliability was

established prior to scoring and maintained throughout

the study by having two coders independently rate 20%

of the tapes. Inter-rater reliability assessed via weigh-

ted kappas ranged from .86 to .88.

Results

The dependent measures were first analyzed for vio-

lations of assumptions of the statistical procedures, and

1030 J Autism Dev Disord (2007) 37:1024–1039

123

it was found that skewness and kurtosis were less than

an absolute value of 1 and thus did not need to be

corrected (Fidell & Tabachnick, 2003). Variance was

assessed by examining Levene’s test for homogeneity

of variance. For variables where Levene’s test was

significant, Fmax ratios were calculated. None of the

Fmax ratios were greater than 4 and thus the data was

considered to have met statistical assumptions (Fidell

& Tabachnick, 2003). We also assessed deviations from

linearity by examining the predictor by residual plots,

which exhibited random scatter.

General Analysis Strategy

For each play variable, both at time 1 and at time 2,

the analysis strategy used was designed to examine

three basic questions: (a) Are there group differences

in play?; (b) What other developmental variables best

predict individual differences in play?; and (c) Do

predictive relationships differ as a function of group?

Multiple regression was used to address each of these

questions in successive steps: first we examined the

main effect for diagnosis using dummy codes to

represent specific contrasts (i.e., autism vs. DD, and

DD vs. Typical); second we used a stepwise entry

procedure with the group of predictor variables (imi-

tation, JA, executive functioning, MA) to explore

which variable(s) best predicted play after accounting

for group differences; third, following any significant

effects for predictor variables, we examined any group

by predictor variable interactions using centered

product vectors to explore whether such predictive

relationships found on the second step differed as a

function of group. We first report the results of such

analyses for the play variables at time 1, followed by

the same analyses for play variables at time 2. Note

that for time 2, however, all play variables were com-

puted as absolute change from time 1 scores in order to

effectively partial out time 1 from time 2 play scores.1

We tested whether the three groups had significant

differences in our demographic measures: CA, overall

MA, verbal mental age (VMA) and non-verbal mental

age (NVMA) at time 2. Table 1 shows these means for

each group. A single multivariate analysis was per-

formed with each of our demographic measures as a

dependent variable and group as the fixed factor. The

overall MA for the groups was not significantly

different (F(2, 40) = .146, P = .86), which was expected

since they had been matched on overall MA. There

was no significant difference in VMA (F(2, 40) = 1.90,

P = .16), or NVMA for the groups (F(2, 41) = .20,

P = .82). As expected, the difference between the

three groups on CA was significant, (F(2, 40) = 94.88,

P < 0.001). Socio-economic status did not differ

significantly between groups.

Before presenting results from the regression mod-

els, we will first look at correlations between the four

time 1-predictor variables. As can be seen in Table 2,

there were significant relationships between overall

MA and each of the other three variables; in contrast,

there were no significant correlations between any of

the three domains of JA, imitation, and spatial reversal

As such, these latter three time 1-predictor variables

are assumed to measure relatively independent

domains, whereas overall MA is a measure of general

developmental level (and thus its ubiquitous relation-

ship with most other measures).2 Next, we will briefly

address the issue of matching here by reporting group

demographic comparisons at time 2 along with the

same analyses at time 1.

Analyses of Time 1 Variables

Group Differences in Development of Play at Time 1

As shown in Tables 3–6, the first step of each three-step

multiple regression analysis reveals that there are

significant group differences for all measures: both

spontaneous and scaffolded pretend play and sponta-

neous and scaffolded sensorimotor play at time 1.

Group contrasts, as represented by dummy codes,

show that the autism group exhibited less pretend play

at time 1 than the DD group in spontaneous and

scaffolded conditions. Similarly, the autism group

showed less sensorimotor play than the DD group in

both spontaneous and scaffolded conditions. The

difference between the typical group and the DD

group in play was not significant, for any condition.

Thus, children with autism demonstrated a develop-

mental delay in all play measures at time 1 even

though all were matched on developmental maturity.

In contrast, the DD and typical groups did not differ.

Group Demographic Comparison at Time 2

Next, we tested whether the three groups had significant

differences in our demographic measures: CA, overall

1 The same analyses done using play scores at time 1 as a truecovariate (i.e., entered into the model even before group diag-nosis) yielded the same results, albeit with the expected drop inpower when using additional variables).

2 It should be noted however, that for the AD group, whenanalyzed separately, there was a significant relationship betweenJA and Imitation (r = .44, P = .03).

J Autism Dev Disord (2007) 37:1024–1039 1031

123

MA, VMA and NVMA at time 2. Table 1 shows these

means for each group. A single multivariate analysis was

performed with each of our demographic measures as a

dependent variable and group as the fixed factor. The

overall MA for the groups was not significantly different

(F(2, 40) = .146, P = .86), which was expected since

they had been matched on overall MA. There was no

significant difference in VMA (F(2, 40) = 1.90, P = .16),

or NVMA for the groups (F(2, 41) = .20, P = .82). As

expected, the difference between the three groups on

CA was significant, (F(2, 40) = 94.88, P < 0.001).

What T1 Measures Predict Pretend Play Development

at Time 1?

The second block of the regression analyses examined

the relationship between each of the predictor vari-

ables of interest: JA, imitation, spatial reversal, and

overall MA.

Spontaneous Pretend Play. As shown on Table 3

diagnosis by itself accounted for 23% of the variance

(F(2, 35) = 5.18, P < .05) in pretend play at time 1.

Once the variance associated with diagnosis was

removed, no other predictor variable was a significant

predictor of development of spontaneous pretend play.

Scaffolded Pretend Play. As shown in Table 4,

diagnosis again accounted for a significant amount of

the variance in scaffolded pretend play: 28%. Once the

variance associated with diagnosis was removed,

overall MA was a significant predictor of scaffolded

pretend play at time 1. Furthermore, the third step of

the analysis shows that this relationship differs as a

function of group, F(5, 32) = 8.24, P < .001. Specifi-

cally, the interaction terms revealed that MA is a

stronger predictor of scaffolded pretend play in the

DD group (r = .31) than in the AD group (r = .13); in

contrast, the relationship between scaffolded play and

Table 3 Summary of hierarchical regression analysis forvariables predicting time 1 spontaneous pretend play scores

Step Variable B SE(B) ß DR2 F for DR2

1 Diagnosis 1(autism vs. DD)

–1.59 .51 –.53* .23 5.18*

Diagnosis 2(DD vs. typical)

–.52 .62 –.14

Note. 37 participants were included in the analysis

*P < .05; **P < .01; ***P < .001

Table 2 Correlations of time 1 predictor variables

Overall MA Spatial reversal Imitation

JA r = .37 r = .15 r = .14P = .004 P = .32 n.s.

Imitation r = .51 r = .18P < .001 P = .22

Spatial reversal r = .51P < .001

Table 5 Summary ofhierarchical regressionanalysis for variablespredicting time 1 spontaneoussensorimotor scores

Note. 38 participants wereincluded in the analysis� P = .05; *P < .05;**P < .01; ***P < .001

Step Variable B SE(B) ß DR2 for step F for DR2

1 Diagnosis (autism vs. DD) –4.40 1.24 –.55** .34 9.31**Diagnosis (typical vs. DD) .72 1.54 .07

2 Diagnosis (autism vs. DD) –4.16 1.18 –.51** .10 8.76***Diagnosis (typical vs. DD) 1.67 1.51 .17Spatial reversal .167 .07 .31*

3 Diagnosis (autism vs. DD) –3.41 1.19 –.42** .07 6.61***Diagnosis (typical vs. DD) 2.05 1.49 .20Spatial reversal .40 .13 .74**SR · Diagnosis (autism vs. DD) –2.79 1.37 –.39�

SR · Diagnosis (typical vs. DD) –2.66 1.51 –.32

Table 4 Summary ofhierarchical regressionanalysis for variablespredicting time 1 scaffoldedpretend play scores

Note. 38 participants wereincluded in the analysis� P = .05; *P < .05;**P < .01; ***P < .001

Step Variable B SE(B) ß DR2 for step F for DR2

1 Diagnosis (autism vs. DD) –5.72 1.86 –.45** .28 7.19**Diagnosis (typical vs. DD) .78 1.98 .06

2 Diagnosis (autism vs. DD) –5.10 1.67 –.40** .09 10.46***Diagnosis (typical vs. DD) .45 1.76 –.40MA (time 1) .44 .12 .42**

3 Diagnosis (autism vs. DD) –5.2 1.56 –.41** .08 8.24***Diagnosis (typical vs. DD) .54 1.71 .04MA (time 1) .76 .18 .73***MA · Diagnosis (autism vs. DD) –3.84 1.48 –.40*MA · Diagnosis (typical vs. DD) –2.27 2.20 –.13

1032 J Autism Dev Disord (2007) 37:1024–1039

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MA was statistically equivalent between the DD group

and the typically developing group (r = .62). No other

predictor variable was a significant predictor of devel-

opment of scaffolded pretend play.

Spontaneous Sensorimotor Play. For spontaneous

sensorimotor play, diagnosis accounted for 34% of the

variance (F(2, 35) = 9.31, P < .01). Once the variance

associated with diagnosis was removed, only spatial

reversal (ß = .31, P £ .001) predicted spontaneous

sensorimotor play at time 1. Results showed that

product vectors were significant predictors of sensori-

motor play development since there was a significant

group by spatial reversal interaction (F(5, 32) = 6.61,

P < .001). Examination of individual interaction terms

revealed that spatial reversal was a significantly stron-

ger predictor of spontaneous sensorimotor play for

children with DD (r = .62) than it was for children with

autism (r = .19). In contrast, there was no difference in

this predictive relationship when comparing children

with DD to typically developing children (r = .41).

Scaffolded Sensorimotor Play. For scaffolded sen-

sorimotor play, diagnosis accounted for 31% of the

variance F(2, 35) = 7.54, P < .01). Once the variance

associated with diagnosis was removed, only spatial

reversal (t(36) = 2.22, P = .03) was a significant pre-

dictor of scaffolded sensorimotor play at time 1. No

other predictor variable significantly predicted scaf-

folded sensorimotor play scores at time 1. Results

showed that product vectors were significant predictors

of sensorimotor play development since there was a

significant group by spatial reversal interaction (F(5,

36) = 6.38, P < .001). Examination of individual

interaction terms revealed that spatial reversal was a

significantly stronger predictor of scaffolded sensori-

motor play for children with DD (r = .73) than it was

for children with autism (r = .08). There was also a

significant difference in this predictive relationship

when comparing children with DD to typically devel-

oping children (r = .34).

Analyses of Time 2 Variables

Group Differences in Pretend and Sensorimotor Play at

Time 2

Scaffolded and spontaneous pretend and sensorimotor

play scores are shown in Table 7. The difference in

spontaneous pretend play scores at time 2 was signifi-

cantly different between the three groups, (F(2,

43) = 12.2, P < .001), as was the difference in scaf-

folded pretend play (F(2, 51) = 5.45, P = .007); the AD

group showed fewer examples of pretend play than the

two control groups in both cases. More specifically, the

AD group showed significantly lower spontaneous

pretend play scores than the DD group ((t) = 3.50,

P = .001) whereas the DD group and the typical group

did not differ significantly ((t) = .85, n.s.). In addition,

the AD group showed significantly lower scaffolded

pretend play scores than the DD group ((t) = 2.27,

P = .028) whereas the DD group and the typical group

did not differ significantly ((t) = .62, n.s.).

In contrast, there were no group differences in either

spontaneous sensorimotor play or scaffolded sensori-

motor play, though the AD group showed fewer

examples of spontaneous sensorimotor play than the

other two groups.

What T1 Measures Predict Development in Pretend

Play from Time 1 to Time 2?

The second block of the regression analyses examined

the relationship between each of the predictor vari-

ables of interest: JA, imitation, spatial reversal and

overall MA at time 1 and changes in pretend play

scores between time 1 and time 2. Complete results

appear in Tables 8 and 9.

Spontaneous Pretend Play. As shown in Table 8

diagnosis by itself accounted for 14% of the variance

and was a significant predictor of pretend play devel-

Table 6 Summary of hierarchical regression analysis for variables predicting time 1 scaffolded sensorimotor scores

Step Variable B SE(B) ß DR2 F for DR2

1 Diagnosis 1 (autism) –13.6 4.6 –.47** .31 7.54**Diagnosis 2 (typical) 5.04 5.6 .15

2 Diagnosis 1 (autism) –12.2 4.4 –.42 .12 7.26**Diagnosis 2 (typical) 8.4 5.5 .24Overall MA (time 1) .29Spatial reversal (time 1) .31*

Note. 36 participants were included in the analysis

*P < .05; **P < .01; ***P < .001

J Autism Dev Disord (2007) 37:1024–1039 1033

123

opment. Once the variance associated with diagnosis

was removed, only JA at time 1 significantly predicted

spontaneous pretend play development accounting for

another 12% (change in R2 = .12) of the variance.

Once the variance associated with both diagnosis and

JA was removed, no other variable predicted sponta-

neous play development over time.3

In the final step of each regression analysis, we

examined possible interaction effects of JA with diag-

nosis in order to determine whether play development

in the different diagnostic groups may be dependent on

different processes. We examined possible interactions

by creating product variables by multiplying JA

Z-scores (calculated across all three groups) by the

diagnostic dummy variables. Results showed that these

product variables were not significant predictors of

pretend play development in any of our four analyses.

In other words, JA affects development of pretend play

similarly across the different diagnostic groups.

Scaffolded Pretend Play. Diagnosis again accounted

for a significant amount of the variance in scaffolded

pretend play: 17%. Once the variance associated with

diagnosis was removed, no other predictor variable was

a significant predictor of development of scaffolded

pretend play.

Sensorimotor Play. Neither diagnosis nor any of the

predictor variables significantly predicted change in

either spontaneous or scaffolded sensorimotor play

scores over time.

How do Performance and Competence Compare?

One important question driving this longitudinal study

is the question of play performance versus underlying

competence. We used spontaneous play as a marker of

Table 7 Group means on play measures at time 2

Scaffoldedpretend play

ScaffoldedSM play

Spontaneouspretend play

SpontaneousSM play

Autistic disorder (n = 28) 9.81 35.05 2.7 13.2SD = 9.25 SD = 19.53 SD = 2.6 SD = 5.9

Developmentaldisorder (n = 18)

16.5 31.36 5.7 18.6SD = 9.8 SD = 23.37 SD = 2.0 SD = 3.8

Typical (n = 27) 19.81 46.31 6.6 20.3SD = 11.05 SD = 34.6 SD = 2.0 SD = .65F(2, 51) = 5.45 F(2, 51) = .086 F(2, 43) = 12.2 F(2, 51) = 1.41P = .007 P = .91 P < .001 P = .25

Table 8 Summary of hierarchical regression analysis for variables predicting change in spontaneous pretend play scores

Step Variable B SE(B) ß DR2 for step F for DR2

1 Diagnosis (autism vs. DD) –1.96 .94 –.40* .14 2.5Diagnosis (typical vs. DD) –.40 1.21 –.06

2 Diagnosis (autism vs. DD) .28 1.37 –.06 .12 4.5*Diagnosis (typical vs. DD) .95 1.31 .15JA (time 1) 1.36 .64 .53*

3 Diagnosis (autism vs. DD) –.24 1.54 –.05 .03 .59Diagnosis (typical vs. DD) 1.08 1.55 .17JA (time 1) 1.18 1.26 .46JA · Diagnosis (autism vs. DD) –.33 1.90 –.07JA · Diagnosis (typical vs. DD) 1.88 2.3 –.18

Note. 47 participants were included in the analysis

*P < .05; **P < .01; ***P < .001

Table 9 Summary of hierarchical regression analysis forvariables predicting change in scaffolded pretend play scores

Step Variable B SE(B) ß DR2 F for DR2

1 Diagnosis 1 (autism) –7.85 3.4 –.39 .17 4.2*Diagnosis 2 (typical) .36 3.6 .02

Note. 48 participants were included in the analysis

*P < .05; **P < .01; ***P < .001

3 Note that in a hierarchical regression in which MA, imitationand spatial reversal are forced in before JA, JA still predicts asignificant amount of variance in spontaneous pretend playdevelopment (P = .002) whereas no other predictor, while forcedin ahead of JA, predicts a significant amount of variance.

1034 J Autism Dev Disord (2007) 37:1024–1039

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performance, to tell us whether a child is likely to

voluntarily engage in play, and scaffolded play as a

marker of competence, to tell us whether a child can

engage in play, given extensive social support and

modeling. In order to directly compare scaffolded

and spontaneous play scores, we converted each to

Z-scores, so that each participant had one Z-score for

scaffolded pretend play and one Z-score for spontane-

ous pretend play. The average Z-score for each variable

for each group is shown in Fig. 1. We know from the

above group comparison that the AD group has sig-

nificantly lower scores on both scaffolded and sponta-

neous pretend play. We directly compared these

relationships by using the Z-scores in a 2 (spontaneous

vs. scaffolded) by 3 (group) ANOVA, which reveals an

interaction between these two play scores and group

membership (F(2, 42) = 4.4, P = .02). In the post-hoc

analysis, the autism group showed a different relation-

ship between these two measures than either the DD

group (P = .02) or the typical group (P < .001). (There

was no main effect of spontaneous vs. scaffolded, which

is what would be expected since we were comparing

independently derived Z-scores). For the autism group,

spontaneous pretend Z-scores, our measures of per-

formance, are significantly lower than scaffolded pre-

tend Z-scores, our measure of competence. For the

other groups the differences between spontaneous and

scaffolded scores did not reach significance. Thus,

children with autism show much less spontaneous

symbolic play, compared to their scaffolded production,

than do the other groups. Either the group with autism

is much more responsive to social modeling than typical

or delayed children (which seems unlikely), or children

with autism have much more difficulty generating play

schemas than other groups (as suggested by Jarrold and

others (Jarrold et al., 1996)).

Discussion

This longitudinal study was designed to contribute to

our understanding of the development of pretend play

in typically developing children, children developing

with autism and children with other developmental

disabilities. One major aim of this study was to test

several theoretical accounts of the nature of pretend

play, both in typical development and in autism.

Accounts tested included cognitive maturation, a

metarepresentational theory of pretend play, an exec-

utive function theory of pretend play, and a social

learning, or imitative theory of pretend play. A second

major aim was to examine the pretend play compe-

tence, as well as performance, in young children with

autism. Past research on pretend play in autism has

often focused only on performance, examining

frequency and novelty of spontaneous pretend play

acts in particular. Since some authors have suggested

that the deficit in autism involves generating the play

ideas (the performance aspect), as opposed to being

capable of representational play (the competence

aspect), we provided a scaffolded condition in which

adults provided increasing support for generating

symbolic play ideas, and compared children’s produc-

tions of both spontaneous and scaffolded play. Finally,

we were interested in the specificity of the play deficit.

Is pretend play the only type of play affected by

autism, or is sensorimotor play also impaired?

The specificity question was addressed by examining

both sensorimotor play and pretend play. At time 1,

when children had an MA of just under 2 years old, the

autism group showed a deficit in all kinds of play:

pretend and sensorimotor, and for both performance

(spontaneous) and competence (scaffolded) measures.

However, by the time of the second visit, when chil-

dren had an MA of around 3 years old, the autistic

deficit in play was specific to pretend play, and not seen

in sensorimotor play. This deficit appears to be an

autism-specific deficit, as the developmentally delayed

group did not significantly differ from controls in pre-

tend play.

This contrast bears on the theoretical question

concerning generativity deficits. The executive func-

tion hypothesis involving generativity and set shifting

would predict deficits in spontaneous play compared

to scaffolded play in both pretend and sensorimotor

conditions (though the pretend condition could be

more affected because the play ideas are coming

Performance and Competence Compared

-0.5

-0.4

-0.3

-0.2

-0.1

0

0.1

0.2

0.3

0.4

0.5

DD IA Typ

DD IA Typ

Z-s

core

Spontaneous

Scaffolded

Fig. 1 Spontaneous and scaffolded pretend play performance inthree groups: developmental delay, idiopathic autism, and typical

J Autism Dev Disord (2007) 37:1024–1039 1035

123

from a repertoire of ideas, where the sensorimotor

play ideas arise from the affordances of the materials

themselves). There was no significant group differ-

ence in spontaneous or scaffolded sensorimotor play

scores, whereas there were significant group differ-

ences in both spontaneous and scaffolded pretend

play scores, for the autism group only (as illustrated

in Fig. 1). Our results agree with past research on

similar groups showing a specific pretend play deficit

in autism that is not restricted to spontaneous pro-

duction. Thus, the play deficit is specific to pretend

play and affects both spontaneous and scaffolded

play. This suggests that, in these groups, pretend play

scores cannot be explained by a failure to generate

novel behaviors. Note, however that for the autism

group, there is still a significantly greater deficit in

spontaneous than scaffolded pretend play, leaving

open the possibility of some, perhaps small, rela-

tionship between generativity and spontaneous

pretend play.

The regression analyses provide the strongest com-

parison of our focal question: which theoretical per-

spective is best able to predict pretend play

development. We used four measures of ability at

time 1: JA, executive function, imitation, and general

cognitive development, as possible predictors. Each

measure is theoretically tied to an account of the

development of pretend play. Only the JA measure

predicted variability in change scores in pretend play

between time 1 and time 2. JA accounts for a signifi-

cant amount of development in spontaneous pretend

play, even after removing all the variance associated

with diagnosis. As further evidence of the special and

unique role of JA behavior, the JA measure was not a

strong or significant predictor of sensorimotor play

development in our participants. This is a dramatic

demonstration of the strong and unique relationship

between JA and the development of spontaneous

pretend play.

What does JA allow for? What is the mechanism

that explains this relationship between JA and pretend

play? JA is a pivotal concept in several different

theories of typical and autistic development. For

example, these results are consistent with the theory of

mind theory, which suggests that early deficits in a

‘‘shared attention mechanism’’ (measured with JA

measures) leads to theory of mind deficits, including a

failure to understand pretend play. According to this

theory, JA is an important developmental building

block, without which typical theory of mind develop-

ment will not take place.

The current findings do not support a model of

symbolic play that develops directly from dyadic, or

gestural imitation. While the children clearly benefited

from adult modeling of toy-directed actions in the

scaffolded condition, the strong predictive relationship

with JA, but not dyadic imitation, emphasizes the

triadic nature of the social learning involved. Children

need to integrate the partner, and the action on the

object. JA reflects a child’s ability to coordinate mind

and attention with that of a social partner, and allows

the child to take in information from other people.

Dyadic engagement may well underlie triadic

engagement, however. The strong role of JA in pretend

play development found here is consistent with social

orienting models of development (see, e.g. Dawson,

Meltzoff, Osterling, Rinaldi, & Brown, 1998; Mundy &

Neal, 2001). According to this model, young typically

developing children spend much more time spontane-

ously orienting to social stimuli, and therefore have

access to much more social and non-social information,

than children with autism. Development of JA may well

be the result of dyadic processes involving mechanisms

underlying emotions or affect sharing (Hobson, 1993).

If affect is not easily or spontaneously shared, reflected

and experienced in young children with autism, the

typical motivation or reinforcement for engaging in

pretend play with another may be reduced. While

dyadic processes may be important foundations for the

development of triadic processes, the present study

clearly demonstrated a unique reliance of pretend play

development on triadic processes involving JA. It is,

however, striking that there is no significant interaction

to indicate that the relationship between JA and

pretend play development is different across different

groups. The cognitive underpinnings of pretend play

development may therefore be similar in the different

groups that we tested.

It is surprising that the other predictor variables

tested here were not significant predictors of pretend

play development. Imitation, as an index of social

learning was tested as a predictor of both kinds of play.

All three groups of children demonstrated enhanced

performance in the scaffolded over the spontaneous

condition, and thus demonstrated enhanced perfor-

mance using immediate imitation. However, a separate

measure of imitative ability in a structured task was not

a strong or significant predictor of either of the pretend

or the sensorimotor play performance. One possible

explanation is the nature of the measure itself. In

contrast to our JA measure, our imitation measure did

not probe spontaneous vs. instructed imitation, delayed

imitation, or multi-step imitation. It is possible that

more extensive measures of imitation would account

for more variance in pretend play, if used in future

studies.

1036 J Autism Dev Disord (2007) 37:1024–1039

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Spatial reversal was expected to be a predictor of

pretend play. Set shifting would seem necessary to shift

one’s perspective between the real and imagined

interpretation of a pretend scene. Nonetheless, our

executive function measure did not predict pretend

play development. An even more surprising result is

that overall MA at time 1 was not a significant predictor

of pretend play development. Overall developmental

level did not influence variability in play development

once other sources of variability were controlled.

However, overall developmental ability certainly

shares some variance with JA and other variables being

tested here. Our main variables are not independent of

each other, as has been demonstrated in many previous

studies, and shared variance may be the primary reason

why other variables do not add significantly once both

diagnosis and JA variability are removed.

It is important to mention that our measure of

general cognitive development was overall MA, which

included VMA. Because verbal development is known

to be impaired in children with autism, many research

projects factor out VMA in their analyses. We decided

not to factor out VMA in the results presented here.

We believe that language (as a symbolic system) and

pretend play (often called symbolic play) may rely on

the same underlying symbolic cognitive system.

Therefore, we did not want to factor out the very

cognitive process that we hoped to measure. When we

did run regression analyses factoring out VMA and

found no essential changes in the results; in particular,

JA measured at time 1 remained the strongest and

only significant predictor of pretend play at time 2,

even with the variance attributed to verbal develop-

ment accounted for.

According to our results and others, there are deficits

in both pretend play competence (our scaffolded pre-

tend play measure) and performance, in autism at this

age. This is important, since deficits in competence are

less readily explainable by a lack of motivation, inter-

est, or the propensity to produce novel acts, compared

to deficits in performance. Indeed, the contrast between

scaffolded pretend play and scaffolded sensorimotor

play indicates strong group differences unique to

pretend play.

We hope and expect that our findings will be

extended by future research. We are currently col-

lecting data for this cohort at time 3, and expect that

even stronger conclusions will be drawn from the

extension of this longitudinal study. In addition, a fu-

ture study would be strengthened by adding complexity

to some of the predictor variables. In particular,

executive function is a many faceted cognitive ability,

including generativity initiation of goal directed

behavior, inhibitory control, working memory, and

flexible control of attentional processes. A measure of

executive function that includes more of these factors

may yield different results. In addition, an imitation

measure that measures both spontaneous and scaf-

folded imitation, and immediate and delayed imitation

would provide a more complete measure of imitation,

and could yield different results. Finally, a future study

that included more subjects might allow for clearer

correlational analyses and even regression analyses

within group. However, such a study would have to be

massive, since recruiting and retaining these groups

over time for a longitudinal study, when one is gener-

ally limited to a particular geographic area, is already

quite cumbersome and costly.

Our last important finding concerned the role of JA

in development of pretend play development across our

different groups. There were no group interactions: JA

predicted pretend play development roughly equally in

all groups. The implications of this finding are striking.

This finding speaks to the delayed versus deviant

question. Because the relationship is the same across

groups, it could be that developmental processes are the

same in the different groups (not deviant) but that

pretend play is delayed in autism because JA is delayed

in autism. The delay in JA may be the explanation for

the delay in pretend play development in autism.

This is consistent with the idea that pretend play is

dependent upon children’s ability to share interests and

attention with others. It may be, as theory of mind

theory indicates, that JA behavior is the first marker of

intersubjective awareness and that it marks the coming

on line of the cognitive system that supports meta-

representation, and with it, pretend play. While the

current findings weigh early social knowledge more

heavily than early executive abilities in pretend play

development, there is much more to be learned about

how early dyadic social processes, as well as triadic

processes, affect later symbolic development.

Acknowledgements SJR and SH were partially supportedby National Institute of Child Health and Human Develop-ment Grant #PO1HD35468. SJR was also supported byNational Institute of Deafness and Communication DisordersNIDCD Grant #R21 DC05574. The support of the Devel-opmental Psychobiology Research Group and the Collabo-rative Programs of Excellence in Autism are gratefullyacknowledged.

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