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Development of symbolic play through the use of virtual reality tools in children with autistic spectrum disorders : Two case studies
Gerardo Herrera, Francisco Alcantud, Rita Jordan, Amparo Blanquer, Gabriel Labajo and Cristina De Pablo Autism 2008 12: 143 DOI: 10.1177/1362361307086657 The online version of this article can be found at: http://aut.sagepub.com/content/12/2/143

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Development of symbolic play through the use of virtual reality tools in children with autistic spectrum disorders
Two case studies
GERARDO HERRERA
Spain Universitat de Valencia Estudi General, Universitat de Valencia Estudi

autism 2008 SAGE Publications and The National Autistic Society Vol 12(2) 143157; 086657 1362-3613(200803)12:2

FRANCISCO ALCANTUD
General, Spain

R I TA J O R DA N
Intervencin, Spain

University of Birmingham, UK Centro Comunica de Diagnstico e

A M PA RO B L A N QU E R GABRIEL LABAJO

Autismo Burgos, Spain Autismo Burgos, Spain

C R I S T I N A D E PA B L O

A B S T R AC T

Difculties in understanding symbolism have been documented as characteristic of autistic spectrum disorders (ASDs). In general, virtual reality (VR) environments offer a set of potential advantages for educational intervention in ASD. In particular, VR offers the advantage, for teaching pretend play and for understanding imagination, of it being possible to show these imaginary transformations explicitly. This article reports two case studies of children with autism (aged 8:6 and 15:7, both male), examining the effectiveness of using a VR tool specically designed to work on teaching understanding of pretend play. The results, conrmed by independent observers, showed a signicant advance in pretend play abilities after the intervention period in both participants, and a high degree of generalization of the acquired teaching in one of them.

K E Y WO R D S

autism; imagination; pretend play; virtual reality

ADDRESS

Correspondence should be addressed to: R I TA J O R DA N , School of Education, The University of Birmingham, Edgbaston B15 2TT, UK. e-mail: r.r.jordan@ bham.ac.uk

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Virtual reality
Computer programs are increasingly being used in clinical practice for psychological and medical rehabilitation in children (Schneider, 1998) and also in educational practice (Alcantud, 2000; Grifths, 1997; Riva et al., 1998). It has been claimed that virtual reality (VR), like other computer based programs, provides a particularly facilitatory environment for people with autistic spectrum disorders (ASDs) in that it offers structure, visual mediation of learning, opportunities for repetition, affective engagement and, additionally, control of the learning environment (e.g. Strickland et al., 1992). Murray (1997) argues that IT is an effective, comfortable, facilitative and emotionally engaging context for learning in individuals with autism. It is likely, though as yet unproven, that VR will share those characteristics of IT and have enhanced effects (especially in terms of generalization) because of its greater capacity to engage and direct attention, offer control of the environment and engage the participants emotionally. Thus, there are good a priori reasons for using VR as a vehicle for teaching individuals with ASD. The authors have developed a VR-based learning environment where a shopping activity is recreated. Within this learning environment, the tool I am going to act as if . . . (Herrera et al., 2004: see Appendix 1), aimed at facilitating understanding of imagination in people with ASD, has been developed. Imagination is a core difculty in ASD (Wing and Gould, 1979),

Figure 1

Snapshot of the tool I am going to act as if . . .

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and it has been recommended that interventions in ASD should concentrate on such fundamental aspects of functioning (Rutter, 1996) rather than on general cognitive gains.

Imagination and the autism spectrum

Difculties and delay in understanding symbolism, especially in relation to symbolic play, have long been documented as characteristic of people with ASD, and as possibly contributing to social difculties (Jordan, 1999; 2003): social/emotional development and the cognitive development of play inuence each other through a transactional process. Thus there are social, communicative and cognitive consequences of failure to engage in play (Jordan and Libby, 1997; Sherratt and Peter, 2002) and addressing this problem is likely to have considerable and ecologically valid benets. Powell and Jordan (1994) have argued for the effectiveness of a cognitively based curriculum for children with autism, and texts for teaching play cognitively have been developed (Howlin et al., 1999). VR offers a further opportunity for a cognitive approach to the understanding and manipulation of symbols. Imagination involves conscious dissociation from reality and the mental manipulation of the environment, and imaginative behaviour involves spontaneity, intention rather than response, and creativity. Play involves the rst two of these characteristics and symbolic play all three; thus, symbolic play is often characterized as imaginative play. Leslie (1987) has dened pretend play as covering both functional play (using objects, including miniatures or toys, as if they were the object they represent) and symbolic play (using objects as if they were something else, had imaginary properties, or were different from the way they are). Leslie suggests that the autistic difculty lies in understanding and using symbolic play with its associated need for mental state understanding, whereas functional play should be unaffected. Experimental and clinical evidence for this is confused and contradictory, in part because of the failure of many studies to distinguish the symbolic from the functional aspects of pretend play (Jarrold et al., 1993). Attempts to teach pretend play to children with ASDs have usually found that such play can be copied or even cued, but that it does not have the qualities of spontaneity, intention and creativity that distinguish imaginative play (Jarrold et al., 1996; Libby et al., 1998). This has led to the suggestion that play decits in ASD may result not from fundamental difculties in symbolism, but from generativity problems arising from executive functioning faults. Sherratt (2002) was able to teach all ve children in his study to copy and extend taught symbolic play narratives, and some to generalize to other forms of symbolic play. Sherratt attributes the success of his programme to the use of a clear structure, the repetition of familiar 145

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12(2) routines, and the degree of affective engagement. He suggests this enabled the children with ASD to overcome their generativity problems and reveal their capacity to play. VR may provide a similarly facilitatory structure for imaginative understanding through its use of structure, its opportunities for repetition, its ability to encourage intention through control of the learning environment, and its inherent capacity to evoke affective engagement in children with ASD. This study seeks to examine these claims for the advantages of VR, with two individuals with ASD.
AU T I S M

Description of the tool I am going to act as if . . . The contents and strategies in the manual for the tool I am going to act as if . . . include an introduction that reviews the relevant features of play in autism compared to typical development, a proposal for the teaching process, and methods and tests for assessing all the abilities worked on (Herrera et al., 2005). The contents of the manual can be seen in Appendix 1. The research we present here involves one version of the intervention using a touch screen, since the immersive version of Virtual Reality is at present not generally available. The version used is technically more advanced than those used in other studies (Strickland et al., 1992) to date, but necessarily represents only the state of the art at the time. The virtual supermarket provided with the tool has a set of progressive exercises that advance from the mere physical manipulation of the objects when shopping to practice with play rst functional and then symbolic with those objects. The structure for teaching what the tool provides involves following the steps shown in Figure 2, each of which, in turn, requires a set of intervention sessions. Intervention starts with a stage of supermarket exploration, in which the individual with ASD has to manage in the virtual environment, buying things by following the list (see Figure 2) that is provided visually, and paying at the till. In the next stage, functional use, a video is shown for every object, indicating how this object is used in a purely functional way (in the rst section of the video) and in a social way (in the last section). In the subsequent functional play stage, another video shows a child playing with a miniature version of the current object. An example is dressing a doll with a pair of toy trousers, equivalent to the real trousers situated on the supermarket hangers. The stage of imaginary play is divided into three. The rst stage, imaginary play with junk and representational materials, includes a set of videos where the play of the protagonist is no longer functional but symbolic, performing imaginary object substitutions. An example is acting as if a piece of clothing (blue and neutral) were a pair of trousers. In the second stage, an
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Session 2: (detail) Session 1 video reviewing List 3: item 1, tem 2, List 4: item 1, tem 2,

Supermarket Exploration

Session 1

Session 2

Session 3

.......

Session n

Functional Use

Session 1

Session 2

Session 3

.......

Session n

Functional Play

Session 1

Session 2

Session 3

.......

Session n

Imaginary Play

with objects transformations magic

Session 1 Session 1 Session 1

Session 2 Session 2 Session 2

Session 3 Session 3 Session 3

....... ....... .......

Session n Session n Session n

Creative Use

Session 1

Session 2

Session 3

.......

Session n

Figure 2

Teaching steps and session detail

imaginary transformation is shown explicitly, taking advantage of VR. For example, the pair of trousers is transformed into a road (Figure 1). As they represent an imaginary transformation, images are presented framed into a think bubble. In the third stage, related to magic, the same set of transformations is shown but this time without the think bubble, trying to illustrate that this kind of situation can occur magically in reality (or at least in fantasy stories, lms, and so on). This was inserted on the pragmatic assumption that some children would be familiar with media transformations of objects and thus needed to distinguish between this making real of imagination and imagination itself. This carefully stepped approach to teaching, ensuring understanding at each stage, avoids the confusion which could result from the premature use of a VR tool. 147

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12(2) For research purposes, in order to compare the VR program to conventional play teaching, we did not use any additional teaching material such as toys or miniatures. However, for the regular use of this VR tool, it should be used in combination with natural play materials, to provide an even more enriching experience. In summary, this tool aims to enable individuals with ASD to improve their knowledge and autonomous management of real objects equivalent to those worked on in the virtual environment, and to improve their pretend play and their understanding of imagination.

Methodology
Technological development is a continuous process, so the intervention involves using prototypes in such a way that reection on the results improves both the prototype and the intervention plan simultaneously.

Participants The two individuals with a diagnosis of ASD matched the criteria for autism in DSM-IV (American Psychiatric Association, 2000). Both participants were receiving some form of service from the Society of Autism of Valencia (APNAV). Both were also strongly attracted to computers and, for both, conventional approaches to encouraging participation and teaching play had failed. Participant data are included in Table 1.
Participant 1. This boy had good expressive language with imperatives, a few declaratives and long sentences, but no conversation or discourse skills. He was easily able to learn the mechanical components of the learning environment (virtual supermarket), which was a precondition for using the I am going to act as if . . . tool. As his scores in the ToPP (Lewis and Boucher, 1997) showed before starting the intervention, however, he had serious difculties in pretend play. Interviews with parents and professionals revealed that he had a strong fear of any lm situation that involved magic. He also showed difculties in his understanding of mental states, as assessed through sections of the Inventory of the Autism Spectrum (IDEA) test (Rivire, 1997: see Appendix 2) and through the SallyAnn Test without window (Wimmer and Perner, 1983), and with window (Nuez, 1993). Participant 2. This young man had some appropriate speech but none of it was spontaneous. He used some imperatives but no declaratives, spoke in short sentences, had some echolalia, and displayed no conversation or discourse skills. However, he did have a good ability to communicate in writing when asked. He was also easily able to learn the mechanical actions 148

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Table 1

Participants data Participant 1 Participant 2 15:7 89 Absent 40.3 18

Age at the moment of starting intervention Leiter IQ (Roid and Miller, 1996)

8:6 89

Spontaneous acts of initiating communication, as Frequent recorded in both assessment and intervention sessions Structured Test of Pretend Play (ToPP) (months) Non-structured ToPP (months) IDEA [social, language and communication, anticipation/ exibility, symbolization]; maximum score in each category is 24 (see Appendix 2) SallyAnn test, False Belief Task Mentalistic understanding of pretence (specic tests for this research) 29.8 37.3

[13, 12, 15, 11] [11, 13, 11, 10]

Not resolved 41

Not resolved 38

needed for managing the virtual learning environment. He showed very limited pretend play, as ToPP scores show. His scores in the IDEA test (Table 2), together with severe problems in solving theory of mind tasks (SallyAnn, with and without windows), showed he had difculties in general mental state understanding. Difculties in the understanding of pretence were also recorded.

Assessment instruments There were specic questionnaires for collecting any potentially pertinent data (such as the play techniques used before the study, the attitude towards computers), and a clinical history was obtained through interviews with parents and professionals, to obtain background data on the participants. The scores obtained by both participants before and after intervention are recorded in Table 2. The most relevant test for the objectives of this research (ToPP) has two parts: structured and free. In the structured part, play materials are given rst in an elicited way (without any specic instructions about how to use them) and then in an instructed or modelled way. The participants score is doubled if s/he plays in response to elicitation rather than needing modelling or instruction. As this test does not have different sets of items for different assessment points, the same models of play are used both before and after intervention, which inevitably leads to a memory effect in the nal scores. Results from the ToPP test were assessed by four observers (Table 3), two of whom were independent of the research team. To minimize
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Assessment instruments and scores at test and retest Participant 1 Test Retest 33 Participant 2 Test 30 Retest 32

Table 2

Test description and score range

Functional use: assessed with different items in which the person has to choose the right alternative for using any of the 33 objects involved, thus scoring from 0 to 33 pointsa Functional play: SPT from Lowe and Costello (1976), scoring from 4 points (12 months) to 24 points (36 months or more) Symbolic play, structured test: ToPP from Lewis and Boucher (1997), scoring from 1 point (11.3 months) up to 34 points (77.3 months)b Symbolic play, non-structured (free) test: ToPP from Lewis and Boucher (1997), scoring from 1 point (16.9 months) up to 34 points (87.9 months)b Number of free play samples in the free play ToPP test Imagination understanding: mentalistic understanding of imagination, through the use of a specic test in which the user has to choose whether the representation of imaginary contents is associated or not with a comic think bubble through a total of 60 itemsa Magic understanding, indicating which situations are magic and which others are real, also through a total of 60 items (see Figure 3 for example)a
a b

30

20

24

23

22

10.25

16.75

15.5

20.25

10.5

15.5

1.5

5 41

18 59

1 38

9 49

47

59

39

52

Complementary test designed for this research, non-standardized. Given both verbally and non-verbally. Standardized over English population, but used here only with relative value to testingretesting.

disagreements on the functional or symbolic character of the observed play, observers were trained to use the same criteria in their scoring before and after intervention. The samples of behaviour used for ToPP were pretend play events that the individual showed at different observational moments, together with measures of their quantity and category (Leslie, 1987: object substitution, false properties attribution, and disappearing/reappearing), according to the general procedures of the ToPP test.

Intervention programme Both intervention and assessment sessions were conducted in a controlled environment and were video recorded to allow for inter-observer analysis
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Table 3

Scores at ToPP by four observers Participant 1 Structured Pre Post 21 16 17 13 Free Pre 8 8 14 12 Post 12 12 22 16 Participant 2 Structured Pre 15 18 14 15 Post 18 24 19 20 Free Pre 0 2 2 2 Post 6 8 8 6

First observer our team Second observer our team First independent observer Second independent observer

10 7 13 11

Figure 3

Snapshot of the magic understanding test

when necessary. The participants attended the Society for Autism in Valencia, receiving the initial test in the rst half of March and a retest in the rst 2 weeks of June 2003. During the 212 months of intervention, each individual received a total of 28 intervention sessions, lasting 2030 minutes each (approximately three sessions per week). 151

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Results and analysis

Reliability measures All the correlations of the assessments made by observers were highly signicant: the correlation was 0.877 (p = 0.004) between observers from the team and 0.923 (p = 0.001) between external observers. Finally, correlation between external and internal observers was 0.838 (p = 0.009). Functional understanding and use The participants understanding of the functional use of each object in the supermarket was checked as a prerequisite for the following levels of teaching. Participant 1 increased his spontaneous functional use of objects after the intervention, and was able to generalize from the virtual to the real environment. For example, his mother reported that, after starting to use the VR tool, the child started to say I am going to use the toothbrush correctly, repeating exactly the use of this object he had learnt through the videos of functional use. The same thing occurred with other items such as the trousers, the sausages, the sandwich, and so on. Both participants showed a good level of functional play, obtaining scores near the maximum before (and after) intervention. Symbolic understanding The rst participant, as shown in Table 2 and Figure 4, showed considerable progress in structured pretend play, obtaining an improvement of 6.5 points in ToPP (from a 29.8 months level of typical play development to 42.8 months). He gained 5 points in the more relevant free play test, advancing from 37.3 months (free play age) to 48.1 months. The good expressive language of this participant appeared to be important in his understanding and use of the symbolic content. Generalization to other environments, people and situations was reported by both parents and professionals. The advances shown by the second participant were also in both types of play (structured and free: see Table 2). In the structured play test he gained 4.75 points (from 40.3 to 49.8 months) and in the free play test he gained 5.5 points (from 18 months to 29.8 months). Parents and teachers did not report any generalization of this play to other situations, however. Imagination understanding In relation to understanding imagination as a mental state, which was represented through the use of comic think bubbles, the rst participant showed a very signicant increase in his ability to determine which of the given
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35 30 25 20 15 10 5 0 1 11.3 29.3 49.3

30

E B
10

E B

20

Typical Development Participant 1 Participant 2

69.3 months

Figure 4

Progress in the scores of the structured ToPP

situations corresponded with reality and which with imagination, recorded through the teachers impressions and through specic tests (see last rows of Table 2). In these tests, an increase of 18 points from a total of 60 were recorded, correctly resolving almost all the items (59), with all of them involving contents different to those worked on through the intervention. Equally positive results were found in the magic understanding test (Figure 3). Results from the second participant in both tests were also very positive but not as notable; he obtained increases near to 20 percent, but did not manage to successfully complete all of the items.

Discussion
Positive results were found in all the tests used (see Table 2). In the ToPP test, memory effects occurred with the rst participant in just one of the items, resulting in 1 false point in his nal score. Allowing for such possible effects on the scores, results still suggest increased scores in both participants after the intervention period. A further possible contaminating inuence on the results was the increase in the level of attention shown by the participants on the retest compared to the initial test, perhaps because of the increased familiarity with the structured teaching situation during the 2 months of the intervention. In sections III (representational toy alone) and IV (self alone) of the structured test of ToPP, very few (or no) play samples were observed in the rst test session, because of the difculties shown by the child in attending to the teachers instructions, despite her being his usual teacher. We know that people with ASD tend to show greater difculties in nonstructured situations in which it is necessary spontaneously to generate original models of play, apart from any difculties they may have with the understanding of imagination itself. For these reasons, the results of the 153

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12(2) free play test are more relevant, since there were no elicitations, modelling or instructions and all the play samples were original and adequate. In addition, we also asked observers to collect data on the number of free play episodes shown by the participants in a dened period of observation (as this measure is not included in the ToPP procedures). The results indicated a very important increase in both participants (see fth row of Table 2). In order to assess the ecological validity of our results, interviews with parents and educational professionals were undertaken. With the rst participant there was a clear reection of the results of the intervention in his daily life, both in relation to the autonomous use of objects and in the performance of imaginary actions and appropriate play in his usual contexts of interaction. For example, the child began to express his ideas to obtain his mothers attention. He performed symbolic play scenarios such as Look Mummy, I am going to act as if the sock were a beard, and other appropriate and spontaneous samples of play that were different to those trained on the VR. Fear of lms with magic content was replaced by an increasing interest and curiosity towards all imaginary situations. The failure of the second participant to demonstrate any generalized social use of imagination (despite improvements in his scores on the ToPP test) may result in part from the paucity of social contact in his environment. If this is the case, this suggests that to obtain a better outcome, not only in cognitive play but also in the wider and more important social play, it would be necessary to follow a complementary programme oriented towards the initiation and maintenance of social contact. However, the degree of language development may also be an important factor in interpreting the different results of the two participants.
AU T I S M

Future work The results obtained suggest that VR is a useful tool in educational intervention in children with ASD, at least in the two participants who were tested. However, it is necessary to compare the efcacy of this tool with the use of conventional tools. In order to make this comparison possible, we have created a toy-based equivalent version of the VR tool, and that analysis is ongoing. This, and the results from other research on educational interventions in ASD, will help determine the design and content of future tools. Our team intends to replicate this study using a larger number of participants, with the aim of testing and extending the validity of our results. It is also intended to determine more precisely the prole of the individuals with ASD for whom this kind of tool would be of the greatest benet.
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Appendix 1: contents of manual for the tool I am going to act as if . . .

1 For whom it is created 2 Introduction Importance of play in child development Play in children and adults with autism Teaching play in autism The tool I am going to act as if . . . 3 A teaching process Modalities and levels of play The abilities that support play What is the role of these abilities in autism? Structured teaching The steps in the teaching process: shopping and management in the supermarket Teaching functional use Teaching functional play Teaching imaginary play Creativity teaching 4 Assessing Necessary space and materials Test structure, administration and scoring Record sheets and video recording Summary of the whole process 5 Technical specications

Appendix 2: dimensions of the IDEA test (Rivire, 1997) Each dimension score depends on the degree of impairment (minimum 0 to maximum 8). The maximum score for the global test is 96 points.
1 Social 1.1 Relating socially 1.2 Joint attention 1.3 Intersubjectivity and mentalistic ability 2 Communication and language 2.1 Communicative functions 2.2 Expressive language 2.3 Receptive language 155

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12(2) 3 Anticipation and exibility 3.1 Ability to anticipate 3.2 Mental and behavioural exibility 3.3 Conscious of the sense of his/her activity
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4 Symbolization 4.1 Ability to pretend 4.2 Ability to imitate 4.3 Creating and mentally working with pending things

Acknowledgements This work has been carried out thanks to funding from the Spanish Ministry of Science and Technology (PROFIT), the Spanish Ministry of Social Affairs (IDI) and the Regional Government of Valencia, through the projects INMER-II and APRIL. Note
A version of this article in Spanish only appeared in a book Dicultades del Desarrollo: Evaluacin e Intervencin (2007), Pirmide, Madrid.

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