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International Journal of Developmental Disabilities logoLink to International Journal of Developmental Disabilities
. 2022 Jul 12;70(3):416–424. doi: 10.1080/20473869.2022.2095861

Trying a board game intervention on children with autism spectrum disorder in Macau: how do they react?

Ka Ieong Lok 1, Hsu-Min Chiang 2,✉, Yueh-Hsien Lin 3, Chunlian Jiang 1
PMCID: PMC11062269  PMID: 38699498

Abstract

Limited special education and related services are available for children with autism spectrum disorder (ASD) in Macau, especially those who are educated in general education classrooms. No intervention study has been conducted on these children. This study was conducted to explore the relationship between a board game play intervention and board game play behaviors and social communication of children with ASD educated in general education classrooms in Macau. A repeated measures design was used and the results of this study showed the mean occurrence of unprompted board game play behaviors per session during intervention was not significantly different from that during pre- or post-intervention. The mean occurrence of social communication per session during intervention was significantly higher than that during pre- and post-intervention. These findings suggest a positive relationship existed between the board game intervention used in this study and social communication of children with ASD.

Keywords: Autism Spectrum Disorder, social communication, board game, play, Macau

Children with Autism Spectrum Disorder (ASD) have deficits in social communication and social interaction [American Psychiatric Association (APA), 2013]. They experience difficulties in developing and maintaining relationships with peers (APA, 2013). Parents and teachers have reported that these children have difficulties in engaging in play with peers and show high levels of social withdrawal (Clark et al. 2020). Children with ASD attending inclusive kindergartens are found to have low numbers of social play and interactions with peers during free play (Dere 2018). Elementary school-aged children with ASD often engage in solitary activities and display self-stimulatory behaviors on the school playground (Gilmore et al. 2019). Social skills are associated with relationship success, academic achievement, employment, and psychological well-being (Deming 2017, Demir et al. 2012, Lane et al. 2004, Moody and Laugeson 2020). Thus, it is important to address social skills deficits of children with ASD.

Social skills interventions (SSIs) have been conducted to improve social competence in children with ASD (Gates et al. 2017, Hutchins et al. 2020, Moody and Laugeson 2020). They teach children with ASD conversation, friendship, and problem-solving skills (Soares et al. 2022). The teaching strategies used in SSIs can be divided into three categories: individually directed strategies (e.g. modeling, prompting, reinforcement), peer-mediated strategies (i.e. peers are trained to provide interventions or peers are included in interventions), and parent-mediated strategies (i.e. parents are taught effective strategies to teach their child)(Kemp 2017). Individually directed strategies are the most widely used strategies in ASD interventions (Camargo et al. 2014, Chiang 2017). SSIs can be conducted in a group or one-on-one format. Hutchins et al. (2020) conducted a meta-analysis of SSIs single-subject design studies for students with emotional behavior disorder and ASD. They reported that the variations in intervention design and delivery did not significantly affect intervention outcomes and concluded a moderate overall effect across all the SSIs studies. Wolstencroft et al. (2018) conducted a meta-analysis of SSIs group studies for children with high functioning ASD and reported that large effect sizes were found in improved social communication skills, and parental involvement and greater intervention duration or intensity moderated the overall intervention outcomes.

Play is defined as an enjoyable and/or entertaining activity (Trimlett et al. 2022), and accounts for a major portion of one’s childhood (International Monetary Fund 2019). Through play, children rehearse and sharpen social skills. Play benefits children’s social communication development (Bodrova and Leong 2005). Play skills are positively associated with social interaction with peers in children with ASD (Wang 2018). Compared to free play, adult structured play increases social communication of children with disabilities (Mills et al. 2014). Game playing is a form of structured play, and a powerful tool to improve students’ learning in classroom (Millians 1999). Social interactions with peers of children with ASD can be improved through playing games (Morrier and Ziegler 2018). Children with ASD have narrow and special interests, thus, some of them do not engage in socially-based recreational activities as often as children without ASD (Daubert et al. 2015). However, with the use of effective instructional strategies, their interests of playing games with peers can be increased.

Board games are the games in which pieces are moved in pre-determined ways on a pre-marked board (Cambridge University Press 2021). Several studies have taught children with disabilities, including ASD, to play board games. Baker (2000) incorporated the thematic ritualistic activities of children with ASD into BINGO games and reported that these children’s percentage of social interactions and joint attention increased during game playing with sibling. Oppenheim-Leaf et al. (2012) taught children with ASD to play board games and reported that these children acquired board game playing behaviors and were able to generalize game play in a less structured setting. Davis-Temple et al. (2014) taught children with special needs and their peers to play board games using a least to most prompting procedure and found that children increased board game playing behaviors and game related on-task behaviors. Daubert et al. (2015) incorporated a modified power card strategy in board games playing on children with ASD. Their study results indicated that children’s appropriate initiating a turn increased and relinquishing a turn decreased during the intervention. Barton et al. (2018) used peer modeling, systematic prompting, and contingent reinforcement to teach children with disabilities to play board games and reported that the intervention was effective in increasing children’s appropriate and independent board game playing behaviors. Trimlett et al. (2022) used the system of least prompts, visual schedules, peer models, and contingent reinforcement to teach children with disabilities to play board games and communicate with peers with typical development. They found that children’s independent board game play behaviors were increased but no changes in peer-directed social communication after the intervention.

This study

Macau, a special administration region of China, is the world’s largest gaming hub and the world’s second-richest territory in terms of per capita economic output (International Monetary Fund 2019). Macau was a Portuguese colony from the 1550s until 1999. The sovereignty of Macau was transferred from Portugal to China in December 1999. Macau’s estimated population in 2021 is about 630,000, and Han Chinese consists of 89% of the population and the Portuguese consists of 1% of the population (The Word Factbook 2021). Both Mandarin and Portuguese are Macau’s official languages. However, 80% of the people in Macau speak Cantonese (The Word Factbook 2021); Cantonese is the language spoken by and the mother tongue for the majority of the people in Macau.

Macau’s first special education law was published in 1996, and the most current version of the special education law was published in 2020. Students with disabilities and gifted students aged 3 to 21 years are offered with free special education services in regular and special schools by the Macau government under the new special education law. However, only the students with disabilities who do not have intellectual disability can be educated in general education classrooms. Macau’s special education law does not require a special education teaching license for special education teachers. There is no teacher preparation program in Macau specifically preparing teachers for students with disabilities. Eighty-seven percent of the schools in Macau are private schools and public schools only accounts for 13% (SCDT 2020). Private schools and public schools perform differently in complying with Macau’s special education law. It is not unusual for students with disabilities to be rejected by private schools and receive zero special education services in regular schools. It is common to learn that general education teachers do not understand ASD or know how to teach students with ASD. Special education and related services for children with ASD in Macau are limited. Therapies to help these children can only be found in a small number of clinical settings and organizations. Thus, it is imperative to find not complicated ASD interventions for teachers and other professionals to use in Macau.

Board games are popular among children and readily available in classrooms. Board game interventions tend to be easy to conduct. They have a great potential for teachers in Macau to use. Thus, this study was conducted to explore the relationship between a board game intervention and board game play behaviors and social communication of children with ASD educated in general education classrooms in Macau. The research questions of this study include:

Research Question 1: Does the occurrence of board game play behaviors of children with ASD vary across pre-intervention, intervention, and post-intervention?

Research Question 2: Does the occurrence of social communication of children with ASD vary across pre-intervention, intervention, and post-intervention?

Method

Participants

Six children with ASD participated in this study. The inclusion criteria of this study included: (a) a child had a diagnosis of autistic disorder or Asperger’s disorder by a registered pediatrician or psychologist, (b) he/she was between 8 and 9 years old and this age range was selected based on the review of previous board game studies on children with disabilities (e.g. Baker 2000, Davis-Temple et al. 2014, Daubert et al. 2015), (c) he/she had no hearing or vision impairment, (d) he/she spoke Cantonese as his/her first language, (e) he/she attended a general education classroom, and (f) he/she had basic game skills (e.g. rolled a dice, counted steps). All children were recruited from a child development center in a hospital in Macau. They had been receiving behavior interventions for social communication before participating in this study but their parents reported those interventions did not produce favorable outcomes. At intake, all participants had difficulty in maintaining appropriate social interactions with others and always played alone during free time. Informed consent was received from all participants before the study began. Participants did not receive additional social skills interventions during the course of this study. Pseudonyms were assigned for all participants. Participants’ characteristics can be found in Table 1. Parents of children with ASD in Macau typically do not want others to know their children’s diagnosis and parents of children with typical development tend not to have their children interact with others with disabilities. Thus, no child with typical development was recruited for this study.

Table 1.

Participants’ characteristics.

Participant Sam John Ken Terry Tobias Ray
Age 8 8 8 9 8 8
Gender Boy Boy Boy Boy Boy Boy
Grade 2nd 2nd 3rd 4th 2nd 4th
Cognitive ability Average Below average Average Below average Average Average
Language ability Below average Average Average Average Average Average
Social interaction Poor social interactions with peers Poor social interactions with peers Poor social interactions with peers Poor social interactions with peers Poor social interactions with peers Poor social interactions with peers
Motor development Below average Above average Average Average Below average Average
Attention and behavior problems Attention problems No Impulsive behaviors Attention problems Attention problems; hyperactivity No
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Notes. The characteristics described here are based on parents’ reports.

Setting and materials

This study was conducted at an organization serving people with disabilities in Macau. This environment was selected because it was not possible to find a room in a school in Macau for this study given the school culture in Macau and the nature of this study. Sessions were conducted in a room with a child-size table and 4 child-size chairs. A digital timer was used for all sessions. Each session lasted 15-minutes and included two to four children with ASD and two researchers. The 15-minutes session time was determined based on the intervention design of previous board game play studies (e.g. Davis-Temple et al. 2014, Oppenheim-Leaf et al. 2012) and the availability of the room in the organization. Each session required at least two children to play the board games and each child needed to attend 14 sessions, including 3 pre-intervention, 8 intervention, and 3 post-intervention sessions. Thus, the researchers matched all children’s available time slots and arranged those with the same available time slots in a session. Children sat around the table with a board game placed on the table and two researchers sat diagonally behind children in each session. The researchers were there to facilitate the intervention but not to have social interaction with the children in this study. All sessions were videotaped. Two video cameras were placed diagonally on the corners of the room.

Two board games, ‘Snakes and Ladders’ (see Figure 1) and ‘Brave EQ Mystery Island’ (Wang 2018) (see Figure 2) were used in this study. These two games had a common goal for participants to complete and required participants to take turns to play. ‘Snakes and Ladders’ was used during pre-intervention and post-intervention. ‘Brave EQ Mystery Island’ was used during intervention. The difficulty level of the ‘Brave EQ Mystery Island’ was higher than that of the ‘Snakes and Ladders’. Participants moved their game pieces forward the number of spaces as shown on the dice rolled from the start to the finish with the help of ladders and hindrance of snakes when playing ‘Snakes and Ladders’. When playing ‘Brave EQ Mystery Island’, participants not only moved their game pieces forward, but they also needed to show various social and problem solving skills as required by the game. ‘Brave EQ Mystery Island’ is a board game specifically designed to teach children emotional management and social skills (Wang 2018). The game rules required players to imitate emotions, generate appropriate behaviors to solve problems, and demonstrate appropriate social behaviors while playing the game (Wang 2018).

Figure 1.

Figure 1.

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Snakes and ladders.

Figure 2.

Figure 2.

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Brave EQ Mystery Island.

Dependent measures

Board game play behaviors

The board game play behaviors in this study included unprompted and prompted board game play behaviors.

Unprompted board game play behaviors

An unprompted board game play behavior was defined as a behavior that correctly completed an individual step that was required by the rules of a board game without receiving a verbal prompt (i.e. a researcher told a child what she/he should do), gesture prompt (i.e. a researcher pointed to one part of a board game to let a child know what she/he should do), or physical prompt (i.e. a researcher hold a child’s hand to assist the child to perform a correct game move) from researchers. Unprompted board game play behaviors were coded using event recording.

Prompted board game play behaviors

A prompted board game play behavior was defined as a behavior that correctly completed an individual step that was required by the rules of a board game with a verbal prompt (i.e. a researcher told a child what she/he should do), gesture prompt (i.e. a researcher pointed to one part of a board game to let a child know what she/he should do), and/or physical prompt (i.e. a researcher hold a child’s hand to assist the child to perform a correct game move) from researchers. Prompted board game play behaviors were coded using event recording.

Social communication

Social communication was defined as a verbal or non-verbal behavior that initiated a social interaction or was responded to a social interaction initiated by a social partner(s). To record the occurrence of a social communication behavior, momentary time sampling was used with 15-seconds fixed intervals during the first and last 5 min of each session.

Research design and statistical analysis

The relationship between the board game intervention and dependent variables (i.e. board game play behaviors and social communication) in this study was examined using a repeated measures design. This design allows the study to understand the changes in dependent variables across pre-intervention, intervention, and post-intervention. The pre- and post- intervention phases had 3 sessions and the intervention phase had 8 sessions. The occurrence of each dependent variable was collected by watching the videos filmed during each session. Given the number of sessions in pre- and post-intervention is different from that in intervention, the mean occurrence of a dependent variable per session was used for data analysis. The calculation was performed by using this formula: the sum of the total number of the occurrence of a dependent variable across all sessions in a phase (e.g. pre-intervention, intervention, post-intervention)/the total number of sessions in a phase. Given the small sample size of this study, Wilcoxon signed ranks tests were used to analyze the differences in the occurrence of dependent variables between pre-intervention and intervention, intervention and post-intervention, and post-intervention and pre-intervention.

Procedures

Pre-intervention

Each session began with a brief self-introduction followed by free play with the board game, ‘Snakes and Ladders’. Researchers did not spontaneously provide instructions or prompts to facilitate children’s board game play but only did so when children asked researchers to help them with playing the game during baseline sessions. A session was ended after 15-minutes in duration. These sessions were used to understand children’s board game play skills and social communication before intervention. This phase lasted for 3 weeks, a total of 3 sessions.

Board game play intervention

During the first session, the researchers introduced the board game, ‘Brave EQ Mystery Island’, to the participants, explained the specific rules of the game, and stated the expected game play behaviors (e.g. following the rules of the game, taking turns, having appropriate conversations). The researchers first demonstrated how to play the game and asked children whether they had questions regarding playing the game. After children’s questions were answered, they started playing the game. Researchers provided least-to-most prompts to children to facilitate the board game play when a child did not initiate or complete a step after 3 s during his/her turn or when a child made an incorrect step. The 3 s response latency was selected based on the previous studies using prompting strategies (e.g. Cihak et al. 2006, Heckaman et al. 1998). For example, if a child did not initiate a step during his turn, a researcher provided a verbal prompt by saying ‘Roll the dice’. If the child still did not show the behavior after 3 s, a researcher then used a gesture prompt by pointing to the dice. If the child still did not roll the dice, a researcher used hand-over-hand prompting to assist the child to complete the behavior. A session was ended after 15-minutes in duration. This phase lasted for 8 weeks, a total of 8 sessions.

Post-intervention

The procedures in post-intervention sessions were identical to those in baseline sessions. Researchers did not spontaneously provide instructions or prompts to facilitate children’s board game play but only did so when children asked researchers to help them with playing the game Children played the game, ‘Snakes and Ladders’, as used during pre-intervention freely. This phase was designed to understand whether the effects of the board game intervention could maintain after the intervention was completed and whether the learned board game play behaviors could be generated to a game not taught during the intervention. A session was ended after 15-minutes in duration. This phase lasted for 3 weeks, a total of 3 sessions.

Fidelity of implementation

The pre-intervention, intervention, and post-intervention sessions were implemented by two researchers of this study. A research assistant assessed the fidelity of implementation across sessions via watching video recordings. Implementation fidelity across sessions was 100%.

Interobserver agreement (IOA)

IOA was assessed for one-third of randomly selected sessions across each participant for both game play behaviors and social communication. A secondary coder was trained by the primary coder to code the data. Both coders were graduate students in educational psychology. Coding training ended after an average of 80% reliability across dependent variables was reached. The primary coder independently coded the data from all sessions and the secondary coder independently coded the data for 30% of the randomly selected video recordings across sessions. IOA was assed using this formula: (the number of agreements divided by the number of agreements + the number of disagreements) x 100. In addition to IOA, Cohen's kappa was reported for social communication. IOA and Cohen's kappa are presented in Table 2.

Table 2.

Inter-observer agreement.

Dependent variables Pre-intervention Intervention Post-intervention Confidence Interval Average
Board game play behaviors 99% 98% 93% 93%–99% 99%
Social communication 96% (kappa = .93) 95% (kappa = .89) 95% (kappa = .85) 95%–96% 96%
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Results

Board game play behaviors

The mean occurrence of unprompted and prompted board game play behaviors per session across pre-intervention, intervention, and post-intervention can be found in Table 3. The individual data for each child is presented in Figure 3.

Table 3.

Board game play behaviors and social communication across pre-intervention, intervention, and post-intervention.

Unprompted board game play behaviors
  Pre-intervention Intervention Post-intervention Wilcoxon signed ranks tests
 Mean 5.83 4.85 5.11 Pre-intervention vs. Intervention Z = .11, p = .916
 SD 8.58 1.12 5.99 Intervention vs. Post-intervention Z = .11, p = .916
 Range 0–18.33 3.38–6.50 0–13.33  
Prompted board game play behaviors
  Pre-intervention Intervention Post-intervention Wilcoxon signed ranks tests
 Mean 0.50 1.54 0.56 *Pre-intervention vs. Intervention Z = 1.99, p = .046
 SD 1.22 0.76 1.20 Intervention vs. Post-intervention Z = 1.57, p = .116
 Range 0–3.00 0.50–2.63 0–3.00  
Social communication
  Pre-intervention Intervention Post-intervention Wilcoxon signed ranks tests
 Mean 14.17 24.79 18.17 *Pre-intervention vs. Intervention Z = 2.20, p = .028
 SD 4.21 4.46 9.63 *Intervention vs. Post-intervention Z = 1.99, p = .046
 Range 9–19 19.75–30.50 6–31.67  
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Note. * = p < .05.

Figure 3.

Figure 3.

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Individual data across pre-intervention, intervention, and post-intervention.

Note. The closed diamonds represent unprompted board game play behaviors. The closed triangles represent prompted board game play behaviors. The open squares represent social communication.

Three Wilcoxon signed rank tests were performed to determine whether there was a significant difference in unprompted board game play behaviors between pre-intervention and intervention, intervention and post-intervention, and post-intervention and pre-intervention. Results showed that there was no significant difference in the three pairs of comparisons. Three Wilcoxon signed rank tests were performed to determine whether there was a significant difference in prompted board game play behaviors between pre-intervention and intervention, intervention and post-intervention, and post-intervention and pre- intervention. Results showed that the mean occurrence of prompted board game play behaviors per session during intervention was significantly higher than that during pre-intervention (Z = 1.99, p < .05).

Social communication

The mean occurrence of social communication per session across pre-intervention, intervention, and post-intervention can also be found in Table 3. Three Wilcoxon signed rank tests were performed to determine whether there was a significant difference in the occurrence of social communication between pre-intervention and intervention, intervention and post-intervention, and pre-intervention and post- intervention. Results showed that the mean occurrence of social communication per session during intervention was significantly higher than that during pre-intervention (Z = 2.20, p < .05) and post-intervention (Z = 1.99, p < .05).

Discussion

Limited ASD support services and interventions are available in Macau. Teachers often have limited special education knowledge and receive no training on how to teach students with ASD. Thus, there is a great need to explore possible ASD interventions easy for teachers to apply in Macau. Motivation is a key factor affecting ASD intervention outcomes (Koegel et al. 2010). Game playing has been incorporated into ASD interventions (Baker 2000). Board games are popular entertainment tools for children, and have long been used by educators as instructional tools in classroom (Millians 1999). This study conducted the first intervention study on children with ASD educated in general education classrooms in Macau. Results of this study showed that unprompted board game play behaviors did not vary across pre-intervention, intervention, and post-intervention but the prompted board game play behaviors during intervention was significantly higher than that during pre-intervention. Children’s social communication during intervention was significantly higher than that during pre- and post-intervention. These findings suggest a positive relationship existed between the board game intervention and social communication of children with ASD. None of the participants in this study missed any session or left early. This observation may support the social validity of the board game play intervention used in this study (Barton et al. 2018).

Previous studies on the use of board games for children with disabilities (Baker 2000, Barton et al. 2018, Daubert et al. 2015, Davis-Temple et al. 2014, Oppenheim-Leaf et al. 2012, Trimlett et al. 2022) have reported positive outcomes of board game interventions on promoting unprompted board game play behaviors of children with ASD. Unfortunately, this study did not find a relationship between a board game intervention and unprompted board game play behaviors, but a relationship between a board game intervention and prompted board game play behaviors. The differences between the findings of this study and those from previous studies may be explained by different characteristics of participants and the board games used in this study and previous studies. This study recruited inclusive primary school students with ASD as participants but previous studies mainly focused on preschool children. The board game used during intervention of this study was specially designed to teach children emotional management and social skills but the board games used in previous studies did not have a social-emotional development purpose. The nature of the board game used during pre- and post-intervention of this study was similar to that in previous studies. It seems that the nature of a board game may influence children’s game play behaviors and social communication.

Previous board game studies (Barton et al. 2018, Trimlett et al. 2022) reported improved unprompted board game play behaviors on children with disabilities but failed to find positive social communication outcomes after intervention. The board game used during intervention in this study guided children to display appropriate social communication while they were playing the game. However, the children in previous studies did not learn social communication skills while playing board games. Board games are structured game activities. Children with ASD tend to have more social communication during structured activities than unstructured ones (Chiang 2009). They experience less difficulties interacting with peers during structured play than unstructured play (Morrier and Ziegler 2018). Structured games benefit social interactions of children with ASD (Morrier and Ziegler 2018), but to increase their social play level and complexity, specific instructions should be provided (McDermott et al. 2020, Singer et al. 2014, Suhonen et al. 2015). Structured activities and adults’ instruction are both important in the development of social skills in children with ASD (Davis-Temple et al. 2014). It seems that combining board games play with structured learning may produce better social communication outcomes in children with ASD.

Limitations

Several limitations of this study should be acknowledged. First, the sample size of this study was small. Second, all participants in this study were boys. Third, the children in this study aged between 8 and 9 years. The intervention responses of the children younger than 8 years old and older than 9 years are unknown. Fourth, no children with typical development or children with other disabilities were included in this study. Thus, it is unknown how these children may affect the intervention outcomes.

Conclusion

Playing board games is one of the popular leisure activities among children. Using an activity that children enjoy as an intervention to improve their skills has higher chance to produce positive outcomes. The teachers who have limited intervention knowledge may be more likely to try the intervention that is easy to adopt and has higher chance to be successful. Future studies should be conducted to further explore the effects of board game interventions on children with ASD residing in the places where ASD interventions and support services are limited.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Disclosure statement

No potential conflict of interest was reported by the authors.

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