Playful but mindful: How to best use positive affect in treating toddlers with autism

The best-tested treatments for toddlers with autism spectrum disorder (ASD) are grounded in the principles of applied behavioral analysis (ABA) and blended with developmental science. Examples include Project ImPACT¹ and Early Start Denver Model,² among others. ABA-based behavioral interventions use conditioned reinforcement of target behaviors by giving the child access to desired objects and activities as a consequence of performing target behaviors. Unlike the original ABA technique, discrete trial training, ABA-based naturalistic developmental-behavioral interventions (NDBI) occur in natural environments and employ operant conditioned reinforcement of target behaviors by capitalizing on the child’s interests in objects and activities.^1–3 NDBIs are highly recommended for toddlers and children with autism³

Clinical manuals for NDBI interventions emphasize that clinicians should use modulations of voice and exaggerated facial expressions and gestures to engage toddlers.^1–4 These behaviors are often referred to as “positive affect,” “increased animation,” “modulation of child affect,” and/or “playfulness.” Given the range of clinician behaviors described across these constructs, and the commonalities between them, we will henceforth refer to the following behaviors as “playfulness” within this manuscript: positive affect, increased animation, modulation of child affect, exaggerated facial expressions and gestures. Most NDBIs indicate that playfulness should be thoughtfully employed throughout NDBI sessions in conjunction with other NDBI strategies (e.g. contingent responsiveness, balanced turns, child choice) to maintain engagement and build social reciprocity with the child as they work together towards treatment goals.

However, our clinical and supervisory experiences suggest that many clinicians do not consistently use playfulness as an intervention tool. Instead, according to our observations, many clinicians largely employ neutral affect when providing treatment to toddlers with ASD – even while employing NDBI strategies such as following the child’s lead, contingent responsiveness, and/or balanced turns.

Empirical evidence: Does playfulness play a role?

Despite the emphasis on playfulness as a strategy that is presented in many NDBI manuals as the basis of adult/child social interactions – and the corresponding empirical support for this strategy in the developmental literature¹ – very little research has examined the use of playfulness as a construct within an experimental design.^5,6 Further, the findings of the available research are too limited to be conclusive. Vivanti, Hocking, Fanning, & Dissanayake (2016) found that while preschoolers with Williams’ Syndrome were more likely to imitate during a live interaction with a playful examiner vs. a neutral examiner. However, there was no such difference observed in preschoolers with ASD. This experiment did not find examiner use of playfulness within a live interaction to increase the likelihood of preschoolers with ASD to imitate. However this did not examine child characteristics that may be related to individual responsiveness to playfulness (e.g., child activity level, child interest in toys/objects).⁵ Given the heterogeneity of ASD, it is possible that the use of playfulness as an intervention tool may be more beneficial to some toddlers with ASD, but not others.

It is also possible that playfulness should be used skillfully by clinicians to foster social reciprocity and child engagement by ramping up, or scaling down, depending on in-the-moment child responsiveness to clinician’s use of playfulness.² A different study⁶ that was designed to examine variations in child interest in materials across a 3-to-5 minute dyadic interaction found that an examiner’s level of playfulness mattered for different levels of child interest in materials (i.e., low interest, moderate interest, high interest). Children were more likely to request during trials that were randomized to a positive affect (i.e., playful) condition when they demonstrated a moderate level of interest in the examiner’s materials. This effect was not observed for children with high or low levels of interest in the examiner’s materials⁶. Child interest varied across the 3-to-5-minute interaction for almost all children. These findings support the hypothesis that playfulness/positive affect is a useful strategy that likely requires varying the intensity of this tool as the interaction continues and child interest and behavior varies.

Given that NDBIs emphasize the utility of playfulness as a core component of the intervention^1–3, it is critical to further explore the use of playfulness as an intervention tool. Understanding the overall impact of playfulness as an intervention strategy, as well as its varied use for different child presentations, will increase our ability to develop an instructive teaching guide for clinicians.

Clinical evidence: Playfulness Works

We strongly support clinicians’ use of playfulness as an integral component of intervention for toddlers with ASD. Our combined clinical experience has demonstrated considerable utility of playfulness for addressing some fundamental issues of behavioral therapy for toddlers with ASD, including (a) increasing motivation for social attention to objects and activities and (b) establishing social reciprocity.

Playfulness motivates many toddlers’ attention to objects and activities

NDBIs capitalize on a child’s natural environment by using conditioned reinforcement strategies to elicit target behaviors within a child’s range of interests in objects and activities. However, toddlers with ASD vary: some toddlers have a considerable number of interests, while others have limited, or very few, interests, which makes behavioral therapy insufficient. In our clinical experience, a clinician’s use of playfulness directed towards the child and objects within the immediate environment helps some toddlers with ASD engage with the clinician and/or their environment, enabling learning opportunities around these objects. In a memorable clinical case, a two-year-old boy with ASD consistently rejected efforts of joint engagement and remained asocial and nonverbal after months of DTT-based ABA therapy. Then, during an outdoor session, the clinician newly assigned to the case enthusiastically verbalized interest to the boats sailing in the river (i.e., employed playfulness); the child has seen boats before, without showing interest. The clinician used a loud and excited voice (“Whoa! Look! Big boats!”) and made exaggerated gestures towards the vessels. The child, for reportedly the first time, followed the clinicians’ gestures with his gaze. The child excitedly said “Big boats!” which was reportedly the first use of expressive language in his life. Many prior attempts to direct the boy’s attention to the boats, with more neutral affect, by family members and other clinicians, had failed.

Strategic playfulness can establish social reciprocity

Our clinical experience demonstrates that toddlers with ASD may often show frustration, or not notice, when approached by a clinician – even if s/he attempts to join child-led activities or brings several exciting toys to the session. Beginning sessions with high-pitched greetings, peek-a-boos, and other playful actions has often helped us, and our supervisees, initiate productive NDBI sessions. For example, we have found that when entering play with a toddler who is active and moving about the room from one activity to the next, it might be useful to initially match their level of enthusiasm with playfulness in attempt to gain their attention. Often, we have found that a high level of playfulness can disrupt a child’s over-activity enough for the clinician to be noticed and join the child’s play. Other NDBI strategies can then also be employed in conjunction with playfulness, as clinician and child work on treatment goals. While these clinical observations may be helpful, more research is necessary to maximize this intervention strategy and to develop evidence-based clinical recommendations.

Suggestions

Overall, we recommend that clinicians actively and thoughtfully incorporate playfulness into intervention sessions. For example, clinicians should start most NDBI intervention sessions by employing a high level of playfulness to initiate a social interaction, and boost child engagement, as described in our second clinical example. Playfulness can then be used skillfully throughout the remainder of the interaction to continue to facilitate child attention to objects/people and to maintain child engagement in the interaction. We stress that clinicians should employ playfulness considering each child’s individual responsiveness – both as a broader clinical profile, and on a session-by-session, interaction-by-interaction basis. Playfulness should be actively considered as a tool throughout each intervention session and actively and thoughtfully ramped-up or scaled-down to enhance child engagement and social reciprocity. Playfulness may not be equally appropriate for all toddlers with ASD, in all situations.

Implications for future research

Our observations suggest that clinician’s use of playfulness can be therapeutic for toddlers with ASD. However, few research studies have isolated and examined playfulness as an intervention tool^5,6– and most manuals reference this strategy as ‘clinical skill’ vs. a teachable strategy. It is likely that children with different behavioral presentations may be responsive to varying playfulness approaches (e.g., over-the-top enthusiastic, or contingent on behavior, or muted) and it is important to identify a teachable set of strategies for community clinicians and parents to use given the relative range of NDBI providers that exist for toddlers with ASD – recognizing that parents and community clinicians are the main providers of NDBI. Empirical studies are needed to systematically evaluate the use of playfulness as a specific intervention component for clinicians conducting behavioral therapy. More specifically, the field of autism treatment may benefit from experimental studies examining the use of playfulness as a strategy for different toddler global clinical/in-the-moment behavioral presentations. These experiments will lead to a greater understanding of the impact, and clinical use, of playfulness and result in a teachable set of strategies for clinicians to use within NDBI sessions.