Introduction 1999 1998 1988 1962 1984 2003 1984 1981 1993 2003 1978 1982 1996 1990 1992 1984 1987 2002 Play Behavior and Autism 1981 2003 2003 1979 2003 1979 1984 2003 1987 1994 1997 1988 1998 2001 1988 1996 1984 1984 1984 1990 2001 1990 1984 1981 is 2001 1993 This Study Play behavior in children with autism has been studied before, under various circumstances and on different levels. However, most studies involved subjects older than 42 months of age. The control groups in these studies were mainly subjects matched on mental age (MA), which created substantial differences in chronological age. In this study we investigated play behavior of children with and without ASD, but also of atypically and typically developing controls under the age of 36 months. Several domains of play behavior were analyzed to investigate differences in play behavior between clinical and non-clinical children, and between clinical children with and without ASD. Observing play behavior at this young age provides the opportunity to detect whether the basic play skills of children with ASD are disturbed, or whether the differences appear at a later age when higher levels of play are expected to be shown. We expected the ASD children to lag behind in their level of play behavior already from their first years of life. Play behavior in children with ASD was also examined in relation to attachment quality. We expected that ASD children with secure attachment relationships would be more playfully engaged and socially involved compared to insecurely attached children with the same disorder. Furthermore, as disorganized attachment is the most insecure type of attachment, it was expected that disorganized children would show more delay in ‘social’ play behavior compared to children without disorganized attachment. Method Diagnostic Assessments 2006 2006 1997 1994 2000 1995 Diagnostic Groups n SD SD n SD SD n SD SD n SD SD F p n SD SD n SD SD n n M SD M SD t p M SD M SD t p 1 Table 1 Characteristics of the various diagnostic groups  AD PDDNOS MR LD AC NC M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) Total 12 11 10 8 16 16 Boy/Girl 8/4 8/3 8/2 8/0 13/3 6/10 Age 30.25 (4.81) 27.73 (7.42) 26.50 (5.38) 27.75 (5.68) 20.50 (3.03) 28.00 (1.75) Dev. level 51.17 (4.06) 71.36 (15.98) 55.10 (4.09) 83.63 (8.48) 85.00 (10.46) 98.44 (12.18) Aut. Symp. 36.25 (5.99) 21.55 (14.19) 23.30 (9.86) 7.38 (2.97) 11.13 (6.85)  Security of Attachment −1.96 (3.03) 1.06 (3.34) −1.28 (3.57) 2.19 (2.52) 1.54 (2.32) 2.17 (1.86) Disorg. of Attachment 5.17 (2.95) 2.82 (2.64) 4.00 (3.04) 2.00 (2.33) 2.40 (2.41) 1.50 (1.10) Attachment classification     Insecure-avoidant 2 1 2 0 0 0     Secure 3 6 2 7 6 13     Insecure-ambivalent 0 2 2 0 2 3     Disorganized 7 2 3 1 2 0 Measures Strange Situation Procedure 1978 n 1988 1990 1990 Play Behavior Play behavior was observed according to protocol. The child and the mother were left in the room for ten minutes. The mother was instructed not to stimulate the child to play but to join when the child asked for cooperation in this free play situation. All children received the same set of toys. 1991 1979 2001 1976 1987 The various play behaviors were categorized in manipulative, functional or symbolic play, and these variables were used in the analyses. The amount of time that a child spent actually playing was calculated as the percentage of time the child played of the total time of the play session. The amounts of time the child performed manipulative, functional and/or symbolic play, were calculated as percentages of the time spent playing. When the child did not play, it would typically show other behaviors such as sitting passively. Reliability among the three coders for play behavior was based on 50% of the videotapes. Agreement was reached in 92% of 38 cases. Mean agreement corrected for chance was 0.74 (Cohen’s Kappa). The variable ‘level of play’ was calculated based on the three different levels of play behavior; manipulative, functional and symbolic play. Durations of the three kinds of play behavior were included in the calculation with the following formula: ((1 x duration of manipulative play) + (2 x duration of functional play) + (3 x duration of symbolic play)) / total duration of play. Differential weights were thus assigned to the social and cognitive levels of play. The variable ‘change toys’ was based on the frequency per minute the child initiated play with another toy. The preference of toys was measured by calculating which toys were preferred most during play. 2 Table 2 Correlations between play, characteristics of children and attachment related variables  Age  Developmental level Attachment security  Attachment disorganization Manipulative play Functional play Symbolic play Level of play Duration of play Number of autistic characteristics .23 −.66** −.47** −.41** .28* −.20 −.19 −.23 −.08 Age in months – −.21 .01 −.00 −.02 .06 .03 .08 .07 Developmental level  – .43** −.44** −.33** .30* .21 .35** .19 Attachment security   – −.49** −.00 .08 .09 .14 .14 Attachment disorganization    – .05 −.23 −.09 −.30* −.30* Manipulative play     – −.59* −.15 −.38** .08 Functional play      – −.20 .78** .66** Symbolic play       – .37** .10 Level of play        – .87** *Correlation is significant at the .05 level **Correlation is significant at the .01 level Analyses Play Behavior and Clinical Diagnoses No gender differences were found for the variables ‘duration of play’, ‘manipulative’, ‘functional’ and ‘symbolic’ play, the ‘overall level of play’ and ‘change toys’. Analyses started with an overall analysis (ANOVA) for all groups, taking differences in developmental level and age into account. Next, differences between the clinical groups with and without ASD were analysed. Preference for toys was investigated using ANOVA for the whole sample, taking differences in developmental level and age into account, and for clinical children with and without ASD. Contribution of Attachment To examine whether security of attachment and attachment disorganization contributed to differences in play behavior and preference for toys, analyses with attachment were performed overall, in clinical children and in the group of children with ASD. Play behaviors and preference of toys of children with and without secure attachment, and children with and without disorganized attachment were analyzed. Results Duration of Play Behavior F p t p 3 Table 3 Duration, level and type of play, and change of toys of the various diagnostic groups  Duration of play (%time) Level of play Changing toys (freq/min)  n M (SD) M (SD) M (SD) AD  12 57.32 (22.24) 15.66 (7.29) .04 (.01) PDDNOS  11 68.19 (12.61) 20.00 (5.05) .05 (.02) MR  10 70.20 (10.73) 18.47 (5.03) .05 (.02) LD  8 66.38 (22.45) 20.96 (8.74) .04 (.02) AC  16 69.50 (15.03) 21.47 (5.89) .05 (.02) NC  16 77.19 (15.67) 24.00 (5.34) .05 (.02)   Manipulative play Functional play Symbolic play n M (SD) M (SD) M (SD) AD  12 22.86 (20.68) 32.28 (20.62) 2.19 (7.35) PDDNOS  11 24.90 (18.32) 34.74 (19.55) 8.54 (12.43) MR  10 32.38 (18.65) 35.01 (21.32) 2.81 (5.08) LD  8 17.91 (10.05) 37.53 (26.57) 10.93 (10.99) AC  16 14.66 (9.33) 50.36 (20.48) 4.49 (7.45) NC  16 15.62 (14.95) 56.33 (21.61) 5.25 (7.55) Manipulative, Functional and Symbolic Play F p F p F p 3 t p t p t p 4 Table 4 Play behaviors of children with and without ASD  Duration of play (%time) Level of play Changing toys (freq/min)  n M (SD) M (SD) M (SD) ASD  23 62.52 (18.72) 17.74 (6.56) .04 (.02) Non-ASD  18 68.50 (16.50) 19.58 (6.82) .04 (.02)  Manipulative play (%time) Functional play (%time) Symbolic play (%time)  n M (SD) M (SD) M (SD) ASD  23 23.84 (19.17) 33.46 (19.96) 5.23 (10.38) Non-ASD  18 25.95 (16.75) 36.13 (23.09) 6.42 (8.98) Level of Play F p 3 t p 4 Preference for Toys and Change of toys F p F p F p M SD M SD t p F p 3 t p 4 Quality of Attachment and Play M SD M SD t p M SD M SD t p t p t p 1 t p F p F p F p 5 Fig. 1 Secure and disorganized attachment and mean level of play in children with ASD  Table 5 Play behaviors of children with ASD with and without secure and disorganized attachment  Duration of play (%time) Level of play Changing toys (freq/min)  n M (SD) M (SD) M (SD) ASD-nonB  14 a a .04 (.02) ASD-B  9 a a .05 (.02) ASD-nonD  14 b b .05 (.02) ASD-D  9 b b .04 (.01)  Manipulative play Functional play Symbolic play  n M (SD) M (SD) M (SD) ASD-nonB  14 22.77 (18.59) 30.74 (19.82) a ASD-B  9 25.50 (21.08) 37.67 (19.87) a ASD-nonD  14 27.40 (21.07) 35.98 (16.78) 7.36 (12.31) ASD-D  9 18.30 (15.25) 29.53 (24.09) 1.90 (5.44) a b p p Disorganized Attachment Relationship and Play M SD M SD t p M SD M SD t p t p 1 F p t p F p 5 Children with and without secure or disorganized attachment relationships did not differ on preference for toys. Discussion Our findings highlight the importance of attachment in the development of play of children with autism and other developmental disorders. Attachment quality explained play behavior regardless of the clinical status of the children. Taking developmental level of the child into account, we found that children with a secure attachment relationship spent more time playing. They also showed a higher level of play and more symbolic play behavior. Children with a disorganized attachment relationship spent less time playing, and within the group of children with ASD disorganized attachment was related to lower levels of play. 2002 2003 1978 2007 2004 2001 2000 1986 1984 1989 1999 2003 Limitations of the Study Although studies of play behavior are required at an early age to get more insight into its development, the young age of the children is also a limitation because symbolic play was not yet in reach of many subjects in the current study. However, retrospective parental reports and screening studies mention differences in play behavior already at this young age. Longitudinal studies are needed to follow the development of these children’s play across time to see whether differences in play behavior arise at a later stage, and to examine whether the effects of a positive attachment relationship are lasting. Conclusions and Future Research 1993 2005 2003 2007