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children
Review
Symbolic Play among Children with Autism Spectrum
Disorder: A Scoping Review
Francisco González-Sala 1, * , Irene Gómez-Marí2, * , Raúl Tárraga-Mínguez 2, * , Alba Vicente-Carvajal 1
and Gemma Pastor-Cerezuela 3
Citation: González-Sala, F.;
Gómez-Marí, I.; Tárraga-Mínguez, R.;
Vicente-Carvajal, A.;
Pastor-Cerezuela, G. Symbolic Play
among Children with Autism
Spectrum Disorder: A Scoping
Review. Children 2021,8, 801.
https://doi.org/10.3390/
children8090801
Academic Editors: Marco Carotenuto
and Jun Kohyama
Received: 21 June 2021
Accepted: 9 September 2021
Published: 12 September 2021
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Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
1Department of Developmental and Educational Psychology, University of Valencia, 46010 València, Spain;
alvicar2@alumni.uv.es
2Department of Education and School Management, University of Valencia, 46010 València, Spain
3Department of Basic Psychology, University of Valencia, 46010 València, Spain; gemma.pastor@uv.es
*Correspondence: francisco.gonzalez-sala@uv.es (F.G.-S.); irene.gomez@uv.es (I.G.-M.);
raul.tarraga@uv.es (R.T.-M.)
Abstract:
Symbolic play is considered an early indicator in the diagnosis of autism spectrum disorder
(ASD) and its assessment. The objective of this study was to analyze the difficulties in symbolic play
experienced by children with ASD and to determine the existence of differences in symbolic play
among children with ASD, children with other neurodevelopmental disorders and children with
typical development. A scoping review was carried out in the Web of Science (WoS), Scopus, ERIC,
and PsycInfo databases, following the extension for scoping reviews of the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) statement. The number of papers included in
the review was 22. The results confirm that children with ASD have greater difficulties with symbolic
play than children with other neurodevelopmental disorders and children with typical development,
even when controlling for their verbal age. Difficulties are greater in situations of free or spontaneous
play. Results evidenced that the absence or deficiency in the symbolic play can serve as an early
indicator of ASD between the first and second year of life, the developmental moment in which this
type of play begins.
Keywords:
autism spectrum disorder; neurodevelopmental disorders; pretend play;
symbolic play; toddlers
1. Introduction
1.1. Neurodevelopmental Disorders: Autism Spectrum Disorder
The last classification of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) concerning neurodevelopmental disorders include a wide range of neurological
based disorders that have their origin in childhood, affect child development itself, and
are characterized by deficits in different areas, such as the personal, social, academic, and
occupational [
1
]. Some of the diagnoses included in this categorization are as follows:
autism spectrum disorder (ASD), intellectual disability (ID), communication disorders,
specific learning disorders, or attention deficit hyperactivity disorder, among others.
Due to the great heterogeneity in the presentation of the clinical forms of neurode-
velopmental disorders and the variability of areas that can be affected, clinical diagnosis
could be hindered. In the case of ASD, it is a neurodevelopmental disorder characterized
by persistent difficulties in communication and social interaction in different contexts, and
by reproducing repetitive and restricted patterns of behaviors, activities, and interests.
These symptoms appear in the early stages of development and are not better explained by
intellectual disability (intellectual developmental disorder) or global developmental delay.
These disturbances are permanent and have an impact in affective, academic, occupational
and social areas, among others, causing a clinically significant deterioration [
1
]. Emotional,
communicative and symbolic development can be, in fact, affected in people with ASD [
2
].
Children 2021,8, 801. https://doi.org/10.3390/children8090801 https://www.mdpi.com/journal/children
Children 2021,8, 801 2 of 18
1.2. Symbolic Play Development in Childhood
Play has an important role in children’s development [
3
,
4
], providing motor, cognitive
and, mainly, the social skills [
5
,
6
] related to symbolic play [
7
–
9
]. Some studies [
10
–
14
]
describe a common pattern in the development of the game, starting with manipulative
and exploratory plays, followed by functional and, ultimately, symbolic plays.
Symbolic or simulation play arises between 18 and 24 months of life [
9
,
15
]. It is charac-
terized by the use of objects with a different role to their specific one, that is, assigning fea-
tures to objects that they do not present, as a consequence of the use of
imagination [16,17].
In this kind of play, children acquire different learnings, imitating situations that happen
mainly in their day to day lives [
18
–
20
]. For example, the typical scenario of using a block
of building games as if it were a car [
18
], phoning with a banana [
19
], holding a bottle using
the hand of a doll [
20
], or turning their own body into a plane. Leslie [
21
] distinguishes
three kinds of symbolic play depending on the moment of appearance: the use of objects
as if they were others, the attribution of false features to an object, and, finally, referring
to an object as if it was present. The classification of Sigman and Ungerer [
22
] includes
manipulative play, relational play, functional play, and symbolic play, considering the last
one as the most complex.
1.3. Autism and Symbolic Play
In the case of children with ASD, one of the most common features is the difficulty they
usually experience regarding symbolic play [
23
–
26
]. These difficulties are even considered
an early indicator for the diagnosis of autism [
23
] and its assessment [
18
]. This is also
reflected in the DSM-5 [
1
] by including, among the symptoms of ASD, behaviors such as
the repetition of a particular kind of game, the stereotyped use of objects, the alignment of
toys, the presence of very restricted interests, and deficiencies related to the imagination.
According to some studies [
24
,
27
], in the first year of life, different play patterns can
be detected in children with developmental disorders when comparing to children of
typical development. In the case of children with ASD, symbolic play lacks diversity and
complexity, instead being repetitive and limited [
28
]; it is not spontaneous (as if it were a
type of learned play [29]) rare and varied [25,26].
Baron-Cohen and Howlin [
30
] indicate that difficulties in playing in children with
ASD are due to cognitive problems, such as the fact of understanding the mental states of
others. Along this line, Leslie [
21
] points to the difficulty of children with ASD in mentally
associating two representations, one concerning the real world and the other to pretend to
be another identity. This second representation, associated with ToM, has been pointed
out in children with typical development to pretend play, by Taylor and Carlson [
31
]
and Suddendorf et al., [
32
]. According to Baron-Cohen [
20
], children with ASD have a
representation of the world as it is, and not as it is not. Bigham [
33
] points out that the more
different are the referent and the substitute (that is, the representation of the real world and
the representation feigned), the more difficult it is to relate both kinds of representations
for the child with ASD.
However, Harris [34] relates the difficulties that children with ASD have in “pretend
play” when it comes to their limited knowledge of the real world. That makes it difficult to
act as if something were something else.
Another theory to explain the difficulties of children with ASD in this type of game
has been the weak central coherence theory [
35
,
36
]. This points out that children with ASD
have a strong preference to process the information given in a local context versus a more
global context. This circumstance makes it difficult for the child to understand and perform
certain acts (not real, fake, nonliteral) in a specific context, such as a play context.
Bigham [
37
] points out the greater predictive value of mental abilities in the difficulties
in the generation of pretend play compared to other theories, such as that of the local
processing of information and response inhibition theory.
Riviere [
38
] and Mundy and Sigman [
39
] relate the social, communicative, and language
limitations of people with ASD to the development of symbolic and fictional capacities.
Children 2021,8, 801 3 of 18
These difficulties in symbolic play can be shaped so that children with ASD can substitute
one object for another [40,41], although they are not novel games and lack spontaneity.
Research shows the existence of a remarkable relationship among child play, the age
of development [
42
], and the development of expressive and receptive language [
41
,
43
–
47
]
in children with both typical and atypical development. According to Bigham [
37
], the
delay in the development of language and receptive language predicts the difficulties of
children with ASD in pretend play. This is related to the hypothesis of symbolic deficit
proposed by Baron-Cohen [
20
] and Ricks and Wing [
48
]. They argue that the difficulties in
symbolization are linked to deficits in language, simulation, and mentalization.
This kind of play in children with ASD has been related to certain factors, such as type
of attachment, mental age, mental abilities, and verbal competence [
49
–
53
]. Thus, children
with secure attachment present a higher level of symbolic play and spend more time playing
than children with disorganized attachment [
49
]. Symbolic play has also been associated
with theory of mind (ToM) [
50
,
51
] and verbal skills [
52
]. In this sense, a study by Chang
et al. [
53
] found a relationship between a greater presence of symbolic play and a higher level
of expressive language in children with ASD. Some authors [
54
] considered it necessary, in
the study of symbolic play, to match children with ASD with children of typical development
according to their language development level. Finally, the absence of symbolic play in
children with ASD does not mean that they cannot learn it. Intraverbal training, that is, telling
a child that a particular object is another (for example, stating that a plate is a hat), leads the
child to use a plate as a hat, increasing substitution symbolic play situations [55,56].
Thus, taking all this information into account, the objective of this study was to
synthesize, through a scoping review, the conclusions of research conducted in recent
decades about the difficulties in symbolic play experienced by children with ASD and to
analyze the possible implications for the early identification and diagnosis of ASD. We
structured the scoping review according to one main and three secondary questions.
The initial question that guided this review was as follows:
•
Are the difficulties of children with ASD in symbolic play generalizable to all the
papers, carried out in recent years, included in this scoping review?
•From this main question, three secondary questions subsequently arose:
•
Are these difficulties different from those experienced by children with other neurode-
velopmental disorders and/or children with typical development?
•
Can the situation of play, spontaneous play or by imitation, influence the greater or
lesser presence of symbolic play?
•
Is there any relationship between the variable ‘verbal age of the children’ and sym-
bolic play?
2. Methods
2.1. Search Strategy
This scoping review was carried out following the extension for scoping reviews of
the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA) [
57
]
statement (for further details, see Supplementary Table S1).
The databases consulted for the bibliographic search were Web of Science (WoS), Sco-
pus, ERIC, and PsycInfo. The initial search was conducted on 23 December 2020, combining
the terms “Autism”, “Asperger”, “ASD”, “Symbolic Play”, “Symbolic Game”, “Pretend
Play”, “Typical Development”, “Development Delay” through the Boolean operators
“AND” and “OR”. The combinations of terms were as follows:
•
(autism* OR Asperger OR ASD) AND (“symbolic play” OR “symbolic game” OR
“pretend play”) AND (“typical development” OR “development delay”) in the field
of topic in the case of WoS.
•
(autism* OR Asperger OR ASD) AND (“symbolic play” OR “symbolic game” OR
“pretend play”) AND (“typical development” OR “development delay”) in the fields
of title, abstract and keywords, in the case of Scopus.
Children 2021,8, 801 4 of 18
•
(autism* OR Asperger OR ASD) AND (“symbolic play” OR “symbolic game” OR
“pretend play”) AND (“typical development” OR “development delay”) in the field
of title and abstract, in the case of ERIC.
•
(autism* OR Asperger OR ASD) AND (“symbolic play” OR “symbolic game” OR
“pretend play”) AND (“typical development” OR “development delay”) in anywhere,
in the case of PsycInfo.
The period delineated for the search was from 1943, the year in which the first scientific
article on autism was published [58], to 2020.
2.2. Selection Criteria
The inclusion criteria were: (a) papers written in English or Spanish; (b) that compare
symbolic play in children with ASD, with typical development and/or with other neurode-
velopmental disorders; (c) with a chronological age or a verbal mental age not older than
6 years.
Furthermore, descriptive and/or theoretical papers that did not provide empirical
data about the topic of the review were excluded; papers that did not include a comparison
group in addition to the group of children with ASD were also excluded; and research
not published in scientific journal papers (such as books and conference proceedings) was
also excluded.
2.3. Study Selection
As a result, a total of 81 papers were obtained: 50 in ERIC, 17 in WoS, 11 in PsycInfo,
2 in Scopus and 1 from another source.
The references of each of the selected papers were reviewed, performing a reverse
search process as indicated by Urrutia and Bonfill [
59
], to assess useful references that had
not appeared in the initial search, adding, by that means, a doctoral thesis. Finally, the
search was repeated in the same conditions at the end of January 2021, to find any possible
article published at the end of 2020. However, no new study was found.
Of the 81 selected papers, after the first screening, 30 were eliminated because they
were duplicated in at least two databases. Ten more studies were also removed because
they were not scientific papers.
The title and abstract of the remaining 41 papers were reviewed. After that, 8 stud-
ies that did not include a comparison group and 4 studies not related to symbolic play
were removed.
After this, the remaining 29 papers were downloaded and fully reviewed. Seven of
them were excluded because they did not match with the object of the present study. Thus,
the final number of papers selected for the review was 22.
This whole process of analysis to determine the suitability, or not, of the papers to the
objective of the review was made by two of the authors. Both of them, independently, ap-
plied the inclusion and exclusion criteria. After independent reviews, cases in which there
was divergence in data collection, a consensus was reached because of the participation of
a third researcher.
Regarding the methodological quality of the papers selected for this scoping review,
this was assessed through 10 out of the 18 indicators included in the SQUIRE Guidelines
2.0 quality scale [
60
]. These indicators were title, abstract, problem description, specific
aims, measures, analysis, results, limitations, and conclusions. Two researchers applied the
quality criteria. The papers were classified into three categories according to their quality:
low, medium, and high; and only those classified in the high category were included in
the review. None of the selected papers were eliminated. The whole process is shown
in Figure 1.
Children 2021,8, 801 5 of 18
Children 2021, 8, 801 5 of 18
aims, measures, analysis, results, limitations, and conclusions. Two researchers applied
the quality criteria. The papers were classified into three categories according to their
quality: low, medium, and high; and only those classified in the high category were in-
cluded in the review. None of the selected papers were eliminated. The whole process is
shown in Figure 1.
Figure 1. Flow diagram (according to PRISMA) used in this scoping review. Abbreviations included in the figure: ASD:
Autism Spectrum Disorder; ERIC: Education Resources Information Center; WoS: Web of Science.
2.4. Data Extraction
The information concerning each of the selected studies was as follows: authors who
signed the article; year of publication and journal; the objective of the study; groups of
participants and sample size; and descriptive characteristics of the samples, such as chron-
ological age, mental age, and nonverbal mental age, among others.
3. Results
Table 1 shows a summary of the main characteristics of the 22 papers analyzed in this
review, including the following information: study and year of publication; the purpose
of each study; characteristics of the sample according to the number of children, groups
included in the studies, and chronological, verbal and nonverbal age (when specified in
the study); play related study variables; and main results.
Figure 1.
Flow diagram (according to PRISMA) used in this scoping review. Abbreviations included in the figure: ASD:
Autism Spectrum Disorder; ERIC: Education Resources Information Center; WoS: Web of Science.
2.4. Data Extraction
The information concerning each of the selected studies was as follows: authors
who signed the article; year of publication and journal; the objective of the study; groups
of participants and sample size; and descriptive characteristics of the samples, such as
chronological age, mental age, and nonverbal mental age, among others.
3. Results
Table 1shows a summary of the main characteristics of the 22 papers analyzed in this
review, including the following information: study and year of publication; the purpose
of each study; characteristics of the sample according to the number of children, groups
included in the studies, and chronological, verbal and nonverbal age (when specified in
the study); play related study variables; and main results.
Children 2021,8, 801 6 of 18
Table 1. Main characteristics of the studies analyzed in the scoping review.
Study Object Sample Study Variables Main Results
Riguet et al.
(1981) [61]
To assess the ability of
children with ASD for
symbolic play in
modelled situations
and in free play
n= 30: 10 ASD, 10 DS,
10 TD.
MCA (years): ASD
(10.0), DS (9.5), TD (2.9).
VMA 2.5 years
Free and modeled
symbolic play.
The symbolic fluidity and
content of symbolic play of
children with ASD are poor
compared to other children with
a similar mental age. Symbolic
play is less frequent in children
with ASD. Modeling provides a
higher level of play in children
with ASD, but lower than in
other children.
Sigman &
Ungerer (1984)
[22]
To compare
sensorimotor skills and
play behaviors among
children with TD, ID,
and ASD.
n= 48: 16 TD, 16 ID,
16 ASD
CA (months): TD
(16–25), ID (32–80),
ASD (39–74).
Developmental age
(months): ID (17–38),
ASD (18–38)
Free functional and
symbolic play.
Symbolic play after
receiving an order.
Sensorimotor abilities.
There are no differences in
sensorimotor abilities between
groups. The group of children
with ASD presents less diversity
in functional play and less free
symbolic play, after receiving
indications. There is a
relationship between receptive
language and functional and
symbolic play in the
three groups.
Baron-Cohen
(1987)
[20]
To evaluate the
simulation play of
children with ASD,
comparing it with that
of children with SD and
with TD.
n= 30: 10 ASD, 10 DS,
10 TD.
MCA (years): ASD
(8.0), DS (7.5), TD (4.1).
VMA: ASD/DS
(2.5 years).
N-VMA: ASD (4.9
years), DS (3.8 years)
Free simulation play.
The group of children with ASD
present less spontaneous
simulation play.
Children with ASD who present
symbolic play differ significantly
in terms of the verbal and
nonverbal mental age of those
children with ASD who did not
present symbolic play.
Stone et al.
(1990)
[62]
To determine whether
play and motor
imitation skills are
different among
children with ASD,
children with ID, and
children with
communication
disorders
n= 91: 22 ASD, 15 HI,
19 LI, 15 ID, 20 TD
MCA: ASD (4.6), HI
(4.2), LI (4.5), ID (5.2)
NH (4.3).
IQ: ASD (54.1), HI
(109.8), LI (97.6), ID
(56.9), NH (100).
Verbal communication:
ASD (3.6), HI (2.6), LI
(2.2), ID (1.9) NH (1.2)
Free play.
Imitation play.
Game type (simple,
relational, functional,
symbolic). Number of
game acts. Play time.
The group of children with ASD
uses fewer toys than the LI, HI,
and NH children’s groups, and
has less playtime and
appropriate playtime. Children
with ASD present less functional
play, with no differences
concerning manipulative,
relational and symbolic play.
The number of children with
functional and symbolic play is
lower in the group of children
with ASD. They have fewer
imitation skills.
Libby et al.
(1997)
[63]
To determine the
existence of differences
between children with
ASD, DS and TD in the
imitation of simulation
games of a single action
and different actions.
n= 30: 10 ASD, 10 DS,
10 TD.
MCA (months): ASD
(120), DS (55), TD (28).
Equalized in
comprehension and
expression from 30 to
32 months.
Simulation play.
Task type: simple or
multi-scheme
(follow guidelines).
Attitudes.
The group of children with ASD
presents greater imitation
responses in simple tasks than
the TD group.
In multischeme tasks there are
no significant differences
between the three groups,
presenting the group of children
with ASD with worse scores.
In imitation tasks, the DSA
group presents a more
participatory attitude than
children with TD and DS.
Children 2021,8, 801 7 of 18
Table 1. Cont.
Study Object Sample Study Variables Main Results
Libby et al.
(1998)
[64]
To determine the
existence of differences
in spontaneous play
between children with
ASD, Down syndrome
and typical
development with a
verbal age of
approximately 2 years.
n= 27: 9 ASD, 9 DS,
9 TD.
MCA (years): ASD
(10.03), DS (4.04),
TD (2.01)
Equalized in
comprehension and
expression from 26 to
29 months
Object search, play
with objects and
simulation play.
There are no differences in
exploration time. The group of
children with ASD presents
more sensorimotor play and less
relational play. There are no
differences in functional play
with conventional objects
between groups.
The group of children with ASD
presents less symbolic play than
the other groups. There are no
differences between the groups
in symbolic play where an object
is substituted for another, but
there are differences in symbolic
play concerning the absence of
an object or attributing a false
feature to the object.
Rutherford &
Rogers
(2003)
[50]
To compare the
simulation play
between children with
ASD, DD and TD using
the cognitive
fundamentals of the
simulation play (ToM
and EF).
n= 78: 28 ASD, 24 DD,
26 TD.
MCA (months): ASD
(33.93), DD (34.83),
TD (19.46).
VMA (months): ASD
(13.36), DD (21.42),
TD (23.92).
N-VMA (months): ASD
(24.88), DD (23.41),
TD (22.52)
Simulation play
Predictive variables:
ToM and EF.
Both spontaneous and induced
simulation play in children with
ASD are lower than in children
with other disorders and with
typical development. A
relationship between ToM and
the symbolic play of children
with ASD is established, but not
with executive functions. There
is no significant correlation
between verbal mental age and
simulation play in children
with ASD.
Warreyn
(2005)
[52]
To compare
spontaneous symbolic
play, imitation of
symbolic play,
declarative joint care
and social reference
between children with
ASD and the
control group.
n= 40: 20 ASD, 20
Control group.
MCA (months): ASD
(58.70), Control (62.25).
IQ: ASD (68.80),
Control (70.70)
Language age (months):
ASD (38.17), Control
(47.17)
Symbolic play, social
referencing, joint
attention and symbolic
imitation.
The group of children with ASD
gets less symbolic and
nonfunctional play and less joint
care with their mothers.
However, there are no
differences in social reference
and symbolic play by imitation,
compared to the control group.
Dominguez et al.
(2006)
[65]
To compare the
characteristics of
spontaneous play
among children with
ASD and TD matched
in chronological age.
n= 58: 24 ASD, 34 TD.
MCA (months): ASD
(36.96) TD (56.32).
Symbolic play.
Playing time.
Preference for toys
There are no differences in
symbolic and functional play
between children with ASD and
TD. There are differences in
sensorimotor and relational play.
Children with ASD have
greater play.
Children 2021,8, 801 8 of 18
Table 1. Cont.
Study Object Sample Study Variables Main Results
Rutherford et al.
(2007)
[66]
To examine simulation
play problems among
children with ASD, DD
and TD by comparing
sensorimotor
development using a
longitudinal design
n= 63: 28 ASD, 18 DD,
27 TD.
MCA (months)
Moment 1: ASD (33.9),
DD (34.8), TD (19.5).
Moment 2: ASD (57.6)
DD (59), TD (30.1).
VMA (months)
Moment 1: ASD (16.50),
DD (20.36), TD (23.83).
Moment 2: ASD (29.21),
DD (34.36), TD (39.5).
N-VMA (months)
Moment 1: ASD (23.7),
DD (23.41), TD (23.41).
Moment 2: ASD (38.21),
DD (36.36), TD (35.9)
Spontaneous
simulation play and
modeling. Predictive
variables: Imitation,
Executive Performance,
Joint Attention,
Cognitive maturity.
There are significant differences
in simulation play between
children with ASD and the rest
of the groups, both in
spontaneous and modeled
conditions, at the first and
second times. Specifically, the
group of children with ASD
shows fewer examples of
symbolic play than the rest of
the groups.
It is observed that, while
children with ASD present
difficulties both in the play of
sensorimotor and in the play of
imitation at the first moment, at
the second, these difficulties only
occur in the imitation play.
Joint attention predicts equally
symbolic play at the first and the
second moment in the
three groups.
Naber et al.
(2008)
[49]
To determine the
existence of differences
in manipulative,
functional and
symbolic play in
children under 36
months with and
without ASD
n= 41: 23 ASD,
18 DD y LD.
MCA (months): ASD
(29.04), DD (27.06)
Mean development
level (months): ASD
(60.83), DD (67.78).
Game type
(manipulative,
functional, symbolic).
Game level. Playing
time. Types of toys.
Attachment
There are no differences between
children with and without ASD
in the time spent playing or in
the type and level of play.
Children with ASD spend less
time reading a book or playing
with daily utensils or puzzles.
The type of attachment has an
effect on the kind, level, and time
of play in children with ASD.
Bigham (2008)
[33]
To determine the level
of understanding of
functional and
simulation play in
children with ASD, TD
and LD.
n= 128: 36 ASD, 37 LD,
55 TD.
MCA (months): ASD
(92.56); LD (116.57);
TD (92.56).
VMA: ASD (57.33);
LD (60.03); TD (58.56)
Functional play. Level
of decontextualization
of the object. Body
parts as objects and
gestures to represent
the imaginary object.
There are no differences in
functional play between ASD
and TD groups. Children with
ASD present more difficulties in
simulation plays (substitution of
an object) and simulation
gestures of the object. They have
more difficulty in simulation
when the substitute used in the
simulation is less related to the
referent regarding its shape
and function.
Hobson et al.
(2009)
[67]
To compare the
symbolic play of
children with ASD and
children with DD by
assessing
self-awareness, the
potential for flexibility
in play and investing in
symbolic meanings and
creativity
n= 32: 16 ASD, 16 DD.
MCA: ASD (9.6 years),
DD/LD (10.4 years).
VMA (years): ASD
(5.3), DD/LD (5.0)
Symbolic play.
Self-awareness,
investment in symbolic
meanings, creativity
and fun.
Children with ASD show less
symbolic play than other groups.
This correlates with the lack of
the qualities of symbolic play
presented by children with ASD.
It is observed that the modeled
symbolic play benefits children
with ASD.
Children 2021,8, 801 9 of 18
Table 1. Cont.
Study Object Sample Study Variables Main Results
Pierce
(2009)
[68]
To examine group
differences in symbolic
play behaviors among
children with ASD, DD,
and TD.
n= 121: 48 ASD, 25 DD,
48 TD.
CA from 18 to
24 months
Symbolic, exploratory
and functional play.
Communicative and
Symbolic Behavior
Scale (CSBS).
The group of children with ASD
shows less symbolic and
functional play behaviors than
the TD group. In contrast,
concerning to exploratory play,
children with ASD have a
greater number of behaviors
related to exploratory play than
children with TD.
Lam & Yeung
(2012)
[51]
To compare symbolic
play between children
with ASD and TD. To
examine which
variables correlate with
the symbolic play.
n= 24: 12 ASD, 12 TD.
MCA (years): ASD
(6.11), TD (5.64).
VMA (months): ASD
(70.17) and TD (77.91).
N-VMA (months): ASD
(22.83), TD (24.08)
Symbolic play. ToM:
Executive operation.
The group involving children
with ASD shows significant
deficiencies in symbolic play
concerning to the TD group.
These deficiencies correlate
significantly with the ToM, but
not with the EF.
Thiemann
–Bourque et al.
(2012)
[18]
To examine the
differences or
similarities of symbolic
play between children
with ASD and DD. To
analyze the relationship
between symbolic play
and language.
n= 73: 35 ASD, 38 DD.
MCA (months):
ASD (49.2), DD (49.7).
Symbolic play:
expressive
communication and
listening
comprehension.
Similarities are obtained in the
symbolic play, in terms of
appearance and interest in toys,
between the two groups. The
diversity of symbolic play of
children with ASD is similar to
that of children with other DD.
Significant correlations are
obtained between symbolic play,
language, and cognitive abilities.
Hobson et al.
(2013)
[69]
To examine the
differences in symbolic
play between children
with ASD and DD.
To explore the
correlation of symbolic
play with language,
communication and
social interaction.
n= 57: 41 ASD, 16 DD.
CA 5 years.
VMA: 2.9 years
Simulation play.
Communication and
social interaction.
Children with ASD get lower
scores in symbolic play than
children with other DD, even
though they are matched in
verbal ability.
Deficiencies in communication
and social interaction correlate
significantly with symbolic play
in children with ASD.
Strid et al.
(2013)
[17]
To examine how
children with ASD
differ from children
with TD in symbolic
play, deferred imitation,
and type of parent
comments (synchro-
nized/nonsynchronized)
during play.
n= 43: 20 ASD, 23 TD.
MCA (months): ASD
(66.8), TD (35).
The group involving
children with ASD was
separated into two
groups: mental verbal
age (38.3) and
non-verbal mental
age (13.6).
Symbolic play, deferred
imitation and
parental feedback.
Both symbolic play and deferred
imitation are lower in children
with ASD than in children with
TD. However, symbolic play is
still lower in children with
nonspeaking ASD.
Deferred imitation and
simulation play do not correlate
in any of the groups.
Hobson et al.
(2015)
[70]
To explore the
relationship between
simulation play and
communicative
engagement in children
with ASD, DD and TD.
n= 130: 41 ASD, 17 DD,
72 TD.
MCA (years): ASD
(5.7), DD (5.5), TD (3.9).
VMA: ASD (2.8 years),
DD (2.9 years)
Symbolic play.
Communicative
commitment.
Children with ASD spend less
time in symbolic play states.
Children with DD spend half
their time in symbolic play states.
Children with ASD get a lower
rate of symbolic change of
meaning per minute than those
from the DD group, getting this
rate very similar to that of
children with TD.
Children 2021,8, 801 10 of 18
Table 1. Cont.
Study Object Sample Study Variables Main Results
Bentenuto et al.
(2016)
[42]
To analyze the
characteristics of
symbolic and
exploratory play in
children with ASD, SD
and TD, through the
collaborative play of
mothers and children.
n= 75
Children and mothers:
25 ASD, 25 DS, 25 TD.
MCA (months): ASD
(43.33), DS (36.68),
TD (20.01).
Mental age (months):
ASD (24.21), DS (21.12),
TD (20.01)
Symbolic play,
exploratory play,
collaborative play of
mothers with children.
There are no differences in
symbolic play between the three
groups, with children with ASD
showing the same ability as
children with DS and TD.
However, children with ASD
participate more in exploratory
play than the other two groups.
Lee et al.
(2016)
[28]
To explore the
relationship between
simulation play and the
inner experience of
children’s playfulness
with ASD, DD and TD.
n= 60: 20 ASD, 20 DS,
20 TD
MCA (months): ASD
(67.3), DD (71.2),
TD (58.9)
Symbolic play.
Playfulness.
Children with ASD show
elaborate simulation plays.
There is a significant relationship
between simulation play and
playfulness in children with
ASD, so the more elaborate the
play, the more joyful the
experiences.
Children with ASD have more
difficulty generating symbolic
play ideas, but not
imitating them.
Thiemann
-Bourque
(2019)
[15]
To compare symbolic
and functional play
skills between children
with ASD and TD.
n= 38: 19 ASD, 19: TD
MCA (months): ASD
(74) and TD (34)
Symbolic play.
Expressive
communication and
listening
comprehension
Children with ASD have fewer
symbolic play actions than
children with TD.
There are no differences between
groups in functional play.
ASD = autism spectrum disorder; CA = chronological age; DD = other developmental disorders; DS = Down syndrome; EF = executive
functions; HI = hearing impaired; ID = intellectual disability; LD = specific learning disorder; LI = language impaired; MCA = mean
chronological age; N-VMA = non-verbal mental age; TD = typical development; ToM = theory of mind; VMA = verbal mental age.
3.1. Characteristics of the Participating Samples
A total of 4 out of 22 papers included in this review compared the symbolic play of chil-
dren with autism and children with other neurodevelopmental disorders [
18
,
49
,
67
,
69
]; five
studies compared children with ASD with children with typical
development [15,17,51,52,65];
and thirteen papers included children with ASD, children with other diagnoses and typical
development children [20,22,28,33,42,50,61–64,66,68,70].
Of the papers specifying the type of neurodevelopmental disorders, six of the papers
had a group with Down syndrome [
20
,
28
,
42
,
61
,
63
,
64
]; one paper included a group with
hearing impaired children, another included a language impaired group, another a group
with an intellectual disability [
62
]; and another paper included a group with a moderate
degree of a specific learning disorder [33].
The sample sizes range from 24 [
51
] to 130 children [
70
]. Table 2shows the ranges
of chronological, verbal and nonverbal mental age of the samples included in the studies.
As shown in Table 2, higher chronological age ranges correspond to children with ASD
and other developmental disorders, while the verbal mental age ranges are lower, to be
able to equalize the children of the different groups in verbal age [
54
]. Specifically, only
11 papers match the verbal age of children with ASD with the children of the other study
groups [20,33,51,52,61,63,64,66,67,69,70].
Children 2021,8, 801 11 of 18
Table 2. Mean age ranges (chronological, verbal and nonverbal) of the study.
Age Ranges ASD DD TD
Chronological age range 1.5 to 10.3 1.5 to 10.4 1.6 to 5.6
Verbal mental age range 1.1 to 5.8 1.6 to 5 1.4 to 6.4
Nonverbal mental age range 1.9 to 5 1.9 to 5.6 1.8 to 2.9
ASD = autism spectrum disorder; DD = other developmental disorders; TD = typical development.
The samples included in the studies of the present review have been equalized in
some variables, such as chronological age, [
15
,
18
,
20
,
49
–
52
,
65
–
70
] and mental, verbal or
nonverbal age, such as [
15
,
17
,
18
,
22
,
28
,
33
,
42
,
51
,
61
,
63
,
64
,
66
,
67
,
69
,
70
]. In the case of the study
by Rutherford and Rogers [
50
], groups are equalized in mental age and in nonverbal mental
age, while there do exist differences in verbal mental age or QI [
15
,
18
,
52
]. Other papers
show differences in chronological age [
17
,
22
,
33
,
42
,
61
,
66
] or in mental age [
49
] among the
involved groups.
3.2. Instruments Used for the Assessment of the Symbolic Play
Regarding the assessment of the symbolic play, eight studies used a standardized
instrument. Specifically, two of them [
50
,
66
] used the Fewell Play Scale, 5th edition [
71
],
which consists of introducing the child to toys and waiting for him/her to play sponta-
neously so that, if he/she does not, some behavior is modeled by the experimenter. The
test ends when the child performs three consecutive symbolic play actions or three con-
secutive errors. Two other papers [
15
,
18
] used an adapted version of the Developmental
Play Assessment (DPA [
72
,
73
]), which allows the evaluation of the play in unstructured
and semi-structured tasks for 15 min. The examiner models a symbolic play-act using each
imaginary object, except for free play, where he/she can only touch and imitate the actions
and toys the child performs.
Two other studies [
69
,
70
] used The Test of Pretend Play (ToPP [
74
]), which covers three
aspects of the symbolic play: the ability to substitute one object for another, to refer to an
object that is not present, and to attribute an absent property to an object. Those aspects are
carried out in a semistructured task, where the examiner provides the child opportunities
to imitate what he/she has modeled. However, not all the meanings of symbolic toys
are shaped, so that they can also be generated spontaneously. In the study of [
28
], the
Child-Initiated Pretend Play Assessment (ChIPPA) [
75
] was used during a 30 min session.
In the first five minutes, the child is encouraged to play with toys alone. In the second five
minutes, the examiner models five symbolic play actions, and in the last minutes, does
not model any action. Finally, Pierce [
68
] uses the Communication and Symbolic Behavior
Scales Developmental Profile (CSBS [
76
]), which allows the child to play spontaneously
before modeling some actions. Thus, play is only modeled to encourage the child.
In other papers, the symbolic play was classified according to categories that had
been established in previous studies. Thus, Bentenuto et al. [
42
] encoded the symbolic
play into four categories, as had been carried out in other studies [
77
,
78
]. They differenti-
ated self-directed pretense, other directed pretense, sequential pretense, and substitution
pretense. Some studies [
17
,
49
] used the symbolic play categories of object substitution,
adding a pretend property to a toy, pretending that something exists when it does not
or role-playing [
21
]. Other studies [
64
,
65
] used the categories listed in the classification
of Libby et al. [
64
]. Specifically, these categories of symbolic play are object substitution,
the attribution of false properties, and reference to an absent object. There are also other
categories, such as: not attending, attending, not acting, unrelated behavior, labeling,
showing, attempting to terminate the session, exploration, sensorimotor play, relational
play, and functional play.
Children 2021,8, 801 12 of 18
3.3. Differences in Symbolic Play between Children with ASD and Children with Other
Neurodevelopmental Disorders
Regarding symbolic or simulation play comparison between children with ASD and
children with other neurodevelopmental disorders, some studies [
20
,
22
,
50
,
61
,
66
–
70
] found
that children with ASD present less symbolic play than children with other neurodevel-
opmental disorders. The study by Bigham [
33
] found greater difficulties in children with
ASD compared to children with typical development and children with moderate learning
disabilities in simulation play, highlighting that these difficulties are greater when the
referent is less related to the substitute, either by its form or by its function, suggesting
that greater decontextualization impairs the understanding of simulation play in children
with ASD.
In contrast, some studies [
18
,
42
,
49
] did not find differences between the groups of
children with ASD and other neurodevelopmental disorders. On the one hand, [
63
,
64
] did
not find differences either, when the proposed tasks of play to the child are simple; on the
other hand, in the face of more complex tasks, children with ASD have worse outcomes
than children with Down syndrome. A study by Lee et al. [
28
] did not find differences
between children with ASD, with Down syndrome, and with typical development when
it comes to playing by imitation; however, there are differences between the group with
ASD and the other two groups when the game is free, with the group with ASD being the
one that presents greater limitations in the production of symbolic play. Stone et al. [
62
]
did not find differences in the number of symbolic play behaviors among children with
ASD, children with neurodevelopmental disorders, and children of typical development,
although the number of children with ASD performing a symbolic and functional play
is lower.
3.4. Differences in Symbolic Play between Children with ASD and Children with Typical Development
When the comparison is made between children with ASD and of typical development,
it is found in most studies that children with ASD present greater difficulties in symbolic
play [
15
,
17
,
20
,
28
,
50
,
51
,
61
,
66
,
67
,
70
]. In other cases, there were no differences between
the two groups [
42
,
62
,
65
]. In some of the studies that show differences between the two
groups, it was evident that children with ASD present half of the symbolic play actions than
children with typical development [
15
,
20
,
50
,
66
]. Finally, in the study of Libby et al. [
63
],
no differences were found between the two groups in simple symbolic play tasks, but in
complex play tasks; while in the study of Warreyn et al. [
52
], they found differences, but
not related to symbolic play by imitation.
In short, and taking into consideration the differences in symbolic play between children
with ASD and the two other groups considered, those with ASD spent less time in symbolic
states of play than the rest [
70
], showed less elaborate simulation games [
24
], and also had
a poorer fluidity and symbolic content of the simulation play [
51
,
61
]. Likewise, when the
verbal ages between groups are equalized, all the studies concluded a lower symbolic game
in the group of children with ASD than in the other groups [20,51,52,61,63,64,66,67,69,70].
3.5. Differences in Symbolic Play Modeling (or by Imitation) and Free Play (or Spontaneous)
between Children with ASD, Other Neurodevelopmental Disorders and Typical Development
In the case of free and spontaneous play, children with ASD presented fewer symbolic
or simulation play actions than children with typical development [
15
,
17
,
20
,
50
–
52
,
66
] or
with other neurodevelopmental disorders [
20
,
50
,
66
]. However, in other studies, these
differences were not obtained [
42
,
65
]. In the study by Libby et al. [
64
], differences were
only obtained in situations that implied the absence of an object or the attribution of false
properties to objects. However, there were no differences among children with ASD, Down
syndrome, and typical development concerning the substitution set. Regarding the study
by Naber et al. [
49
], although there was no difference between spontaneous play and play
by imitation, the situation of play exposed to children was spontaneous play, since the
mother did not intervene unless the child requested it. In this study, no differences were
Children 2021,8, 801 13 of 18
found concerning manipulative, functional and symbolic play, between children with ASD
and children with other neurodevelopmental.
Finally, seven papers have studied symbolic modeled play in children with ASD. Four
of them [
28
,
61
,
67
,
68
] found that, although children with autism presented simulation play
less frequently than other groups, in the case of structured, guided and modeled tasks,
the difficulties of children with ASD significantly decreased. Even Warreyn et al. [
52
]
found no differences between children with ASD and typical development in symbolic
play by imitation. This type of symbolic play (modeling or by imitation) gives children
with ASD a higher level of play than free play [
61
]. Similar results are found in the study
by Hobson et al. [
67
], in which it is observed that children with ASD benefit considerably
from modeling play. Likewise, Lee and other researchers [
28
] found that children with
autism present difficulties in the generation of symbolic play, but not in its imitation.
However, it is important to note that modeled symbolic play significantly improves the
symbolic abilities of children with ASD. This play is less frequent than that of children with
other neurodevelopmental disorders and with typical development [
61
]. However, two
papers [
63
,
64
] obtain better results for the ASD group than for the typical developmental
and Down syndrome groups in terms of simple symbolic play imitation, although these
differences are not statistically significant.
4. Discussion
The purpose of this study was to synthesize, through a scoping review, the conclusions
of research conducted in recent decades on the difficulties in symbolic play experienced by
children with ASD and to analyze the possible implications for the early identification and
diagnosis of ASD.
Of the 22 studies analyzed, only three of them found no differences between the
group involving children with ASD and the group with another neurodevelopmental
disorder [
18
,
42
,
62
]; and four studies did not find differences between the group involving
children with ASD and the group involving children with typical development [
42
,
49
,
62
,
67
].
In the case of the study by Bentenuto et al. [
42
], it is necessary to take into account the age
of the children, which is about 21 months, being below 24 months, the age from which the
difficulties in symbolic play in children with ASD are more evident [
52
]. Along the same
line, Thiemann-Bourque et al. [
18
] pointed out that the absence of differences between
children with ASD and other disorders may be related to the lack of language.
Two papers did not find differences between the group with children with ASD and
the group with neurodevelopment disorders in terms of simple symbolic play, in which
they have to imitate a single action, with differences evident when they have to imitate
a symbolic play with different actions [
63
,
64
]. However, 15 studies did find differences
between symbolic or simulation play between children with ASD and children with other
neurodevelopmental disorders, or typical development [
15
,
17
,
20
,
22
,
28
,
33
,
50
–
52
,
61
,
66
–
70
].
All these data help us to answer the initial and main question that structures this article,
since we could confirm that children with ASD have greater difficulties in the production
of symbolic play than children with other neurodevelopmental disorders and children with
typical development.
According to Lam and Yeung [
51
], the difficulties in symbolic play or simulation
in children with ASD can be explained by the theory of mind. To this end, difficulties
in understanding another person’s mind are significantly related to the shortcomings
of the simulation play. This idea is consistent with Leslie [
21
], who pointed out that
children need to have two representations in mind simultaneously to produce symbolic
play. In this sense, the study by Rutherford et al. [
66
] highlighted the importance of joint
attention to the capacity of metarepresentation, understanding it as a forerunner to the
development of the theory of mind and, thus, a predictive variable of symbolic play in the
three groups examined.
Children 2021,8, 801 14 of 18
Likewise, some authors also highlighted, as a predictive variable of the simulation play,
mental age, since they hypothesize the possibility that this game develops as an individual
matures cognitively. Moreover, a study by Bigham [
33
] pointed out the difficulties of
children with ASD to understand the simulation play, while two studies [
54
,
79
] did not
find differences in understanding this type of games between children with ASD and typical
development. However, Bigham [
33
] contended that the greater the decontextualization
between the referent and what is simulated, the more difficulties in understanding there
are. Thus, responding to our second question, the differences are significantly higher in the
group of children with ASD, since there are some inherent characteristics of ASD that make
it difficult for children with this disorder to produce the symbolic play, such as deficiencies
in metarepresentation skills related to ToM [
21
], generating ideas [
40
] or the lack of joint
attention abilities [44,80–82].
Children with ASD also have a lower level of symbolic play than other groups in free
play situations, as obtained by [
15
,
17
,
20
,
50
–
52
,
66
]. Therefore, the conclusions drawn by
several studies allow us to respond to the third of our questions: children with ASD have
greater difficulties in the production of spontaneous or free symbolic play than the children
in the other groups. This can even be related to some aspects of executive functioning,
such as rigidity and poor cognitive flexibility, which would make it difficult to attribute an
object a quality or a not properly attributable use.
In addition, and also regarding the third question, the group of children with ASD
presents greater difficulties than the group of children with neurodevelopmental disorders
and typical development in the production of the symbolic play by imitation or modeling.
However, children with ASD benefit to a greater extent in the production of symbolic
play in modeled play situations than in free play situations [
28
,
52
,
61
,
63
,
64
,
67
,
68
]. This is
because children with ASD present difficulties in generating games, but not always with
the imitation of them, so the difficulty would be associated with a lack of imagination [
28
].
This fact coincides with previous studies that showed that children with ASD present
difficulties in free symbolic play [
24
], implying that they have significant limitations in
their spontaneous production abilities [
83
]. To this end, it is fairly clear that the fact that
children with ASD present higher levels of play in modeled situations than in spontaneous
situations [
83
] is because they imitate symbolic activity, without performing an interpreta-
tion of it, in a guided context [
63
]. According to a study by Lee et al. [
55
], children with
ASD who can verbalize, are between 3 and 6 years and with the presence of functional play
and imitation, can develop a substitution of symbolic play with objects through training.
Finally, studies in which children have been equalized according to their verbal
age [20,51,52,61,63,64,66,67,69,70]
also concluded that the group involving children with
ASD presents a lower symbolic play than children with other neurodevelopmental disor-
ders and children with typical development. This conclusion addresses our fourth and
last question, related to knowing whether having the same verbal mental age provides
the same levels of symbolic play in children with ASD than in other children. We state
that the group of children with ASD show greater difficulties than children with other
neurodevelopmental disorders and children with typical development, although they are
equalized in verbal mental age. In addition to the role that language plays in the develop-
ment of symbolic play [
18
,
52
,
84
,
85
], as was met in the answer to our second question, some
inherent characteristics of the disorder make it difficult for children with ASD to produce
symbolic games.
An important limitation of some of the included studies is the small (lower than
50 participants) sample sizes [
15
,
17
,
20
,
22
,
49
,
51
,
52
,
61
,
63
,
67
,
68
]. Another limitation is that
not all the included studies used a symbolic game evaluation tool; and the context in which
the analyzed studies were carried out: in a laboratory setting, structured and with specific
toys, and not a natural one [
15
,
18
,
52
,
67
,
68
]. This can condition the amount and type of
symbolic play presented by the children included in the studies. Concerning the selection
process of the reviewed papers, the limitations are related to the number of databases
Children 2021,8, 801 15 of 18
conducted (not including, for instance, the Scielo database), and to the type of document
(excluding Library of Congress, books, and chapters of books).
Future research should address the study of symbolic play in children with ASD,
taking into account issues such as the degree of autism, more natural and closer settings
to the child, and using children’s peers as models. In addition, studies are required to
assess the impact of learning symbolic play by modeling on the different areas of a child’s
development. In this sense, it might be considered whether this learning has an effect on
the development of language, and whether this type of learned game can be generalized to
other toys and contexts.
5. Conclusions
The results of this scoping review allow us to confirm that the absence or deficiency
in symbolic play, mainly in situations of spontaneous play, can serve as an early indicator
of ASD diagnosis between the first and the second year of life, just at the developmental
moment at which symbolic play begins. These difficulties occur in children with ASD with
and without verbal language. However, in children with ASD with verbal language, it may
be more unnoticed because of the relationship between language development and play. In
children with ASD, symbolic or simulation play is less frequent, less complex, and differs
significantly from symbolic play skills than in children with other neurodevelopmental
disorders and children with typical development. In addition, children with ASD benefit
from imitation or modeled play situations. That indicates some reliance on the model when
carrying out this type of game. In these cases, participation in symbolic play increases, as
well as in more drawn-up simulation game proposals.
While the lack of symbolic play in children with ASD is a characteristic considered for
the assessment of the disorder [
18
,
23
], this scoping review highlights the importance of
assessing symbolic play, especially in spontaneous and natural play situations (and not in
modeled situations). That differentiation should be considered both in clinical observation
situations and in family interviews.
Eventually, the conclusions in this scoping review invite the exploration of the poten-
tial benefits of including specific interventions to promote the appearance of symbolic play,
both in prevention programs for children at risk of having ASD, and in intervention pro-
grams aimed at language development for reducing social and communication difficulties
of children with ASD.
Supplementary Materials:
The following are available online at https://www.mdpi.com/article/
10.3390/children8090801/s1, Table S1: Preferred Reporting Items for Systematic reviews and Meta-
Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.
Author Contributions:
Conceptualization, F.G.-S., A.V.-C. and G.P.-C.; methodology, I.G.-M., R.T.-M.
and G.P.-C.; writing—original draft preparation, F.G.-S. and A.V.-C.; writing—review and edit-
ing,
I.G.-M.,
R.T.-M. and G.P.-C. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Children 2021,8, 801 16 of 18
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