Author: Linn Wakeford, M.S., OTR/L
This case is presented as 1) an example of how simple scripts can be used to teach constructive/manipulative play skills, and 2) an example of a simple approach to collecting data to support further intervention decisions. This is a single case and the data collection is flawed from a purely scientific perspective, but it does offer a base from which other similar interventions and assessments can be designed based on individual needs of the child.
About Sam
Sam is a 5 year old boy who lives with both his parents in a suburban community and attends an inclusive preschool program not far from his home. Sam was diagnosed at age 3 ? with pervasive developmental disorder, and his parents immediately sought services for him, both in public and private agencies. Sam has developed a great deal of speech in the past year, and interacts verbally with both children and adults. The meaning in both expressive and receptive language varies for Sam, and he has difficulty negotiating social interactions. Sam enjoys computer activities, simple art activities, sensory play, and is beginning to engage briefly in building/constructive activities. However, Sam plays with toys and objects in the same way each time, and seldom engages in play activities that require more than one step, unless an adult is assisting him. He often has difficulty staying focused on an activity, and is mildly resistive to adult prompting to play with toys in different ways.
Background
Sam's intervention team, which consists of his parents, his teachers, an occupational therapist and a speech-language pathologist, felt that Sam needed to expand his play skills to include more variety in his play and more complicated types of play. There was also some question about what would be the most effective method for teaching Sam new play skills. While many children with PDD respond well to visual information and structure, Sam seemed to pay more attention to verbal information. However, since Sam had never been exposed to consistent use of pictures or other visual cues for structuring his activity, it was possible that this might still be a good teaching method for him. After discussion with the team, the occupational therapist devised a structured program of intervention that could be used to test several teaching strategies, and begin work on expanding Sam's play skills at the same time. The program was based on input from team members, knowledge of a variety of teaching strategies, knowledge of current research about PDD and autism spectrum disorders, knowledge about the development of play skills, and information gathered from observation and interaction with Sam in his classroom environment.
Intervention
? The goals of intervention were 1) to expand Sam's play skills (doing more than one step play, using the same materials in different ways, using several items in combination rather than only one toy at a time), and 2) to find a teaching method that was effective for helping Sam expand his play.
? OT intervention in this setting is usually delivered on an integrated model, using the activities in which the child is already engaged as opportunities for intervention within the classroom setting. However, the team decided that in order to clearly assess the usefulness of each teaching method and collect reasonable data, it would be necessary to use a more focused one-to-one intervention model over a six week time period.
? The use of "scripts" in enhancing social play is well-documented, and it was decided that providing a "script," with clear adult and child "parts," for the sequence of a building activity would be used to help structure the intervention.
? It was decided that three methods of teaching would be trialed. The first method would involve only verbal and demonstration cues, the second would involve using color pictures presented in a series, left to right, and the third would involve using the color pictures in series, but with the added component of having Sam remove each picture as he completed that step of the task. The left to right sequence was chosen to support pre-literacy skills.
? While ultimately the goal was to expand Sam's play in many areas, for the purpose of the initial program, block construction was the play activity chosen. This was done for several reasons: Sam had been more engaged in and interested in building with blocks during classroom play recently and it was a common classroom play activity, it was a concrete task that was easy to represent in pictures, and it offered the opportunity to use essentially the same materials in different ways. This would allow the OT to address expansion of play skills/object use in several ways.
? Materials were 4 yellow one-inch blocks, a longer blue block, a toy car and a toy person; each activity was designed to have 6 simple steps.
? The initial building activity was one in which Sam had already begun to engage (building a tower), so the added component was to add a purpose to the building by having him crash a toy car into the tower once it was built. The second building activity used the same items, but expanded by including horizontal as well as vertical building (to make a bridge instead of a tower), and drive the car under the bridge. The third activity was planned to be use of the same blocks, to build a train, and the replacement of the car with a toy person to place on the train. Each activity was to be paired with a separate teaching method, and to last for two weeks.
? The occupational therapist worked with Sam at a small table against the wall in his classroom 3 times per week, doing the particular activity for five trials. Verbal instructions were generally consistent, though needed amendment at times to redirect Sam's attention. A simple data collection sheet was used each session, with the OT recording the type and amount of prompting (verbal, gestural, general physical, or hand-over-hand) that Sam required to complete each of the 6 steps of the activity, in each of the five trials for that day.
? Sam's teachers were encouraged to engage Sam in similar building activities, but with different blocks, during regular classroom play, to encourage generalization of these particular play skills.
Results:
The recorded data indicated that Sam learned best in the first method, in which verbal and demonstration cues were used. He is consistently able to build a tower of blocks and crash a toy car into it, with three or fewer verbal cues only. He also did fairly well using the third method, once he got used to the routine of doing a step and then removing the picture before going on to the next step. However, he continues to need more verbal and gestural cues, and some physical prompting to build a bridge or a train and make purposeful use of what he has built. What was quite clear from the data was that Sam was not able to use the pictures to structure the play sequence when they were in a constant array in front of him. Because the teachers were not always able to engage Sam in similar classroom play on a regular basis, generalization of new building skills really did not occur. This was not unexpected, as generalization is often difficult for children with PDD, but it will need to be addressed with other methods.
Implications:
To be confident in the results, the "preferred" methods must now be applied to engaging in other types of play and learning activities, and must be integrated into regular classroom routines, rather than used only in one-to-one situations. This will be the next step of this intervention process.
In order to teach Sam new and expanded methods of play, the use of verbal and demonstration cues will be useful particularly in situations that are not concrete enough to be represented in pictures, or in situations where it isn't possible to carry around picture boards or other materials. It is also the method that looks most "natural" in school settings, and would be least likely to set Sam apart from his peers. However, using a picture script to learn new concrete or multi-step activities may also be useful in certain circumstances. Because Sam will leave the preschool program and go to kindergarten next year, information about how he responds to various teaching methods will be useful to future teachers and therapists.
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