Department of Psychiatry
Harvard Medical School
The Cambridge Series Conference
Childhood PDD Spectrum Disorders
January 8, 2005

Autism, Language, and Narrative Play Therapy

Ann E. Densmore, Ed.D., CCC SLP/A

Play therapy is based upon the fact that play is the child’s natural medium of self-expression (Axline, 1947, p. 9).

Autism is a disorder that includes “atypical social interaction, disordered verbal and nonverbal communication, poor or limited imaginative play, a need for routine and sameness, and significantly restricted areas of interest and activity” (Bauman & Kemper, 1997, p. 243). However, children with autism—like all children––have the capacity to use meaningful language, play, and tell stories. Children develop the tools of language, play, and narrative through interactions with others. Typically developing children naturally relate to others and use language to express ideas and emotions. Children with autism need much more than exposure to the social interactions of family and peers.

Typically developing children develop early symbolic play and the ability to narrate the actions of others. In contrast, children with autism may use play to repeat stereotypical activities or to handle toys for visual or physical sensations (Wing, 2001). For example, they may create a story about a video character, but the actions and language are often copied and repetitive. Children with autism also become attached to certain toys or routines in play. They need early, long-term, intense treatment that encourages them to engage in the social interactions of play with a trusted therapist and family member.

A child with autism often retreats to his own non-social world, isolated from the social interactions of family and peers. However, there are several ways to intervene and to join the child in a play therapy process that move the child out of the isolation of self-talk, repetitive behaviors, limited language with no vocal turn-taking or contingent responding, and limited or no eye contact. Narrative Play Therapy––an intervention for children with autism––brings together three main areas of innate capacities: language, play and narrative. The goal of Narrative Play Therapy is to help a child integrate these capacities in order to become a well-functioning, communicative, loving and relating child.

This presentation focuses on three children and how certain intervention strategies help these children utilize their natural capacities for language, play and narrative. Their experiences with Narrative Play Therapy provide a window into the therapeutic relationship between the child and the therapist.

Definition of Child’s Capacities for Language, Play, and Narrative

Language

“For children, acquiring language is an effortless achievement that occurs under varying conditions, and in a limited amount of time” (Guasti, 2002, p. 2-3). However, for most children with autism, acquiring language is a struggle, a monumental achievement that occurs with a strong relationship with a therapist and the family. The theories of language acquisition vary, but most linguists agree that human beings are innately endowed with a system of richly structured linguistic knowledge (Chomsky, 1975, 1986) and that typical children, if given the opportunity and time, will acquire language that allows them to develop and communicate with competence.

A child’s perception of sound is evident from birth and speech abilities are evident by 6 months of age with an infant’s first vocalizations of cries, vegetative sounds, and isolated vowel-like sounds. Psychologists Peter Emias and Peter Jusczyk (1971) found that one-month old infants respond to the difference in sounds between a /ba/ and a /p/ by sucking a pacifier linked to a computer that delivers stimuli; the baby’s sucking rate is faster when the syllables change. Jusczyk (1993) also found that infants can discriminate their native language from a foreign language soon after birth.

The beginning of babbling occurs between 6-8 months, a development that is a precursor to sequencing syllables and language. Manual babbling with deaf infants happens at the identical time (Petitto & Marentette, 1991), suggesting that there is a neural substrate that is responsible for babbling. Babbling is an important process in acquiring language (Guasti, 2002). As babbling becomes a practice field for language development, the infant begins to form word/word approximations around 12 months of age and two-word phrases by 15 months.

In the process of acquiring language, the child attaches to the parent and responds in order to get the parent’s attention. In turn, the parent joins the child in imitative babble, sound production, and joint attention events that continue to encourage language development. Infants and parents engage in expressive language through the process of vocal exchanges (Pawlby, 1977). Their ability to form a sequence of reciprocity in communication begins the “social interplay” from the time of birth. Reciprocal interactions with gestures and body language that match what the child is saying are a part of the social interplay between a child and others.

By the time children are one, they use gestures, body language and one-word approximations as they point on their own to gain an adult’s attention. They keep checking to see whether the adult has responded as they point and then gaze back to change the adults’ attention (Bretherton, 1992). Sixteen-month-old infants look longer at objects that have been named for them by a parent (Golinkoff et al., 1994) than infants whose parents did not name the objects. When fifteen month old infants were left in a room in which a voice named an object, they didn’t learn the name of the object; they made the connection only if there was a person present doing the naming (Baldwin, 1991 & Baron-Cohen, Baldwin, Crowson, 1997). Autistic children made mapping errors, associating a name to an object they were looking at and not to an object the experimenter was viewing and naming. Typical children and mentally handicapped children did not make these errors. Children with autism struggle when making the appropriate word associations needed to accurately name objects and events.

By pointing to and naming objects, a parent expands the child’s incomplete utterances that accompany nonverbal gestures. Meaningful pointing to objects with joint attention is also a “precursor to speech” (Murphy & Messer, 1977) and practically all pointing is naturally accompanied with vocalizations. When babies are uncertain, they check on what their mother is looking at or how she is reacting (Bretherton, 1992). Babies engage early in “referential looking” (Jones, 1977), the process of shifting a visual gaze from an object to the mother’s face and then back to the object.

Sharing and pointing along with joint attention is often absent in children with autism, even when shown a room full of toys and objects. Children with autism use “instrumental pointing” to indicate what they want or to show some awareness of needing help, but they cannot indicate to their parent which toy they remember or liked best. Joint attention and pointing abilities may be related to a deficit in the perspective taking abilities that are normal to language learning. When a child with autism is attending to an object in a room and the experimenter names an object that he is not attending to, the child will only associate that name to the object he is looking at (Baldwin, 1991).

For example, a toddler with autism was looking at a toy truck when his mother said, “Tommy, come eat your sausage.” Immediately following this, Tommy called his truck a sausage. This research supports the view that children with autism have word learning difficulties because they learn in most cases through association (Baron-Cohen, Baldwin, & Crowson, 1997).

Perhaps the child with autism lacks the joint attention abilities to attend to what another person is saying and pointing to in these studies. In the mid 1980s and 1990s, researchers found that joint attention abilities were absent in children with autism (Loveland & Landry, 1986; McEvoy, Rogers, & Pennington, 1993; Mundy, Sigman & Kasari, 1994). Even though a child with autism may be sensitive to others, he needs extensive help within language interactions to see the other person’s perspective and to understand what the other participant is doing and thinking. The main idea in learning language is for “the child to be in a situation in which adults talk to children as they engage in various games, with novel words being introduced as naturally as possible into the ongoing flow of the game” (Wetherby & Prizant, 2000, p. 37).

Play

There is little debate that symbolic play is important to the development of a child’s capacity for language and for play with intentional actions (Bretherton, 1984). When acorns are used as plates and cups and a stick becomes a wand, a child understands an object: it represents an action or an item. Piaget (1962) claimed that symbolic play bridges the child’s concrete play experience to abstract thought, enhancing the development of language.

In play, a child takes turns––physically and vocally––with objects and with gestures and sounds. Since “turn-taking is more than just a characteristic of language, whether learned or unlearned, it is necessary for the acquisition of language” (Kaye, 1977 in Locke, p. 114). The practice of these reciprocal vocal turn takings and object manipulations provides the initial groundwork for speech production and relating to others. It is within social interactions between a parent and a child in the context of a play experience, in taking turns, that the child can experience the social, emotional and physical cues that facilitate language and expand play actions.

Current researchers are developing intervention methods based on building relationships through play and interactions that connect the child with autism to others. The concept of integrated play groups was developed as an intervention for children with autism to provide opportunities for game like participation with typical peers (Wolfberg, 1999). As children play, with guided participation (Rogoff, 1990; Vygotsky, 1978), they experience language and play as one unit. They engage, take turns, and learn from each other.

Another widely used therapeutic program that helps children with autism engage with affective interactions in play is the Developmental Individual Difference Relationship-Based Model (DIR). This model helps children learn to communicate and relate through a shared interaction, engagement, and a two-way purposeful communication (Greenspan & Wieder, 2000). Play becomes the medium through which the child and the parent interact with the support of a trained therapist.

During play, which is critical to the development of actions with objects and symbols, language occurs between the child and the parent. The “mediation of joint attention, action, and affect helps children make sense of the social interactions and language that surrounds them”(Wetherby & Prizant, 2000, p. 263). Reciprocal, playful interactions between parents and children are important to language acquisition. Play becomes an important therapeutic situation for language interactions to occur in a natural way between the parent and the child, even a child with autism.

The two systems, language and play, are almost one. Through play, a child learns to read facial cues, see gestures, hear phonological sounds, listen to intonation patterns, and negotiate in a social world.

Narrative

Narrative was first described by Jerome Brunner (1983, 1990) as a way for a child to create meaning out of actions in life and to connect the self to the real world with a story. In the 1990s, researchers began to explore a child’s culture, internal beliefs, and family experiences by analyzing how a child tells a story. A young child creates a narrative and includes a beginning orientation about the place and time of the event, a sequence of actions about the figures or the play, a high point or problem, and an ending that resolves the story (McCabe & Peterson, 1991; McCabe & Bliss, 2003). Story structure is innate in typically developing children. They intuitively understand how to create narratives that have relevant, thematically related, and sequential ideas (Gleason & Ratner, 1993). Creating these narratives help children make sense of their experiences (Gee, 1985; Hymes, 1982).

A child with autism needs time and support to develop his language and play skills in order to create a story structure with figures and themes that are meaningful. Often the child with autism wants to use figures for repetitive non-meaningful actions instead of for a narrative. When he creates a story, it is often a fantasy that he cannot distinguish from real life. For example, he might talk about Thomas trains, repetitively naming them and counting them, and not be able to create a reality story about what he did with his father that day on a visit to a real train yard. A child with autism needs help not only with story structure but also with relating and retelling real life events.

Phases of Narrative Play Therapy

Phase One: First Contact

The initial goal of Narrative Play Therapy is to make a first contact with the child by joining him in what he is doing, even if it is simply watching a reflection on a pond or watching a leaf fall in the wind. A child with any language delay needs to experience a protected, respectful relationship with a therapist. For this experience to take place, the therapist needs to accept that the child has reasons for what he does and that many things may be important to the child that he is not able to communicate (Axline, 1947, 1979).

Language

In the First Contact phase of Narrative Play Therapy, the child with autism is often non-verbal. Sounds may consist of crying or screaming; gestures may be inconsistent and disconnect from the sounds; self-talk is often prevalent; and words are not relevant to the context or the situation. Linguistically, the child has limited word production, irregular phonological sounds and intonation patterns, and poor social affect with no joint attention. Vocal turn taking is limited or absent and sound production is repetitive or often not present.

Play

Play skills are often repetitive and isolated, and actions are without intention. The child wants to line up toys, open a door repetitively, and/or visualize letters or lines on an object in a light. The child uses self-stimulatory behaviors to fixate on environmental shapes and sounds and may flap his hands, jump up and down, or combine this repetitive play with repetitive gestures.

Narrative

Though the child has the capacity to narrate, narrative is often not evident at this time. In this first phase, the child doesn’t relate past events in a logical manner.

Phase Two: Joint Attention

The goal is to keep the child in a joint attention mode by relating to him by using objects, narrating actions, and noticing and responding to his gestures and movements. The objective is to narrate the actions of the child and others and to relate these actions to meaningful events.

Language

In this phase, the child’s language may consist of one-to-two word phrases, word approximations, and/or simple sentences. The child has words for basic emotions. Linguistically, the child is usually naming objects or requesting and protesting. Language is reciprocal on an inconsistent basis. Vocal turn taking is evident but limited and is often not initiated by the child. Body language and gestures are frequently used instead of language in a reciprocal interaction.

Play

The child engages in some symbolic play and still has some repetitive play actions that interfere with relating to others. The child may engage in parallel play with intentional actions with objects or symbolic objects. Actions are meaningful and relevant to a story, and play is visualized by the child. The child’s actions are usually limited to one play area, one play set, and/or one story theme. The child still retreats to his non-social world when frustrated, fearful or in need of quiet time.

Narrative

In this phase, the child’s narrative has a simple story structure: a beginning, a middle sequence of actions, and an ending. The child has difficulty sequencing his thoughts and often finds the details of a story more interesting than the overall theme. The child includes a peer inconsistently in the story and shares objects; however, he still wants to create his own themes, remains inflexible, wants to control the play, and/or play alone.

Phase Three: Child Initiated Reciprocity

The goal is to allow the child to initiate play with reciprocal interactions by experiencing relationships with peers and to express emotions and ideas through story themes. In this phase, the child plans play actions with a peer and differentiates between fantasy and reality play. The child can initiate a narrative and use several play sets with a peer. The child feels secure while he negotiates for his own agenda during play with support from an adult.

Language

In this phase, the child maintains eye contact with a peer, consistently engages in referential looking, limits self-talk, and uses increasingly complex syntax and vocabulary. The child is motivated to use reciprocal and vocal turning, eye contact, and contingent responding.

Play

The child consistently uses symbolic and object-action play with a peer and limited repetitive play with objects. The child allows a peer to change the agenda during play and plans actions with a peer using language. The child’s actions center on a story theme and expand beyond one play set or area. He combines meaningful play actions with language and plans his play with his peer. His complex stories connect details to the main theme.

Narrative

The child’s narrative contains a complex story structure with intricate actions in a logical sequence. The narrative may include both a high point and a resolution. The child can allow others to create a theme or to change the theme of the narrative. He expresses increasingly abstract and meaningful thoughts.

Phase Four: Social Engagement

The goal of phase four is to encourage the child to use reciprocal interactions during play and to expand play to outside locations with a peer, keeping the peer within their play area and communicating with the peer about their relationship.

Language, Play and Narrative

During this final phase, the child is continuously engaged with others in a natural setting. The child uses abstract thinking and relates objects to more abstract thoughts. The child can also visualize a plan and create a story with characters with another child. Sharing and changing play themes as well as following others are integral to the child’s play. Using language to express ideas, plans, negotiate, relate, and bring others into a relationship––the child feels emotionally connected. This final phase involves the child in an independent engagement with others in a social world in natural settings.

Summary

Even a child with autism brings innate capacities to a social environment; he has the ability to use meaningful language, to play, and to tell cohesive stories that create dramas about real and symbolic life events. In play,a child needs to bond to either a parent or a therapist in order to experience the interactive nature of a relationship and the communication that is integral to that relationship. Once a child with autism finds that sharing a relationship is more meaningful than staying within his isolated world of playing alone, he will venture into the social world and relate. As his social capacities begin to appear, he becomes a part of the social world. During each phase of Narrative Play Therapy, the child develops expressive and cognitive language abilities, play actions with intentional themes, and meaningful narratives. The child’s regulation of his sensory needs as well as his awareness of his own and other’s play space develops as a part of this process. The child emerges with language, play and narration as one unit.

References and Suggested Readings

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Ayres, J. (1994). Sensory integration and the child. Los Angeles, CA: Western Psychological Services Publishers.

Baldwin, D.A. (1991). Infants’ contribution to the achievement of joint reference. Child Development, 62, 875-890.

Baldwin, D.A. (1992). Clarifying the role of shape assumption. Journal of Experimental Child Psychology, 54, 392-416.

Baron-Cohen, S., Baldwin, D.A. & Crowson, M. (1997). Do children with autism use the speaker’s direction of gaze strategy to crack the code of language? Child Development, 68, 48-57,

Baron-Cohen, S. (2001). Mindblindness. Cambridge: MIT Press.

Bauman, M. & Kemper, T. (1997). The Neurobiology of autism. Baltimore: The Johns Hopkins University Press.

Bloom, P. (2002). How children learn the meanings of words. Cambridge, MA: MIT Press.

Bretherton, I. (1984). Symbolic play: The development of social understanding. San Diego: Academic Press.

Bretherton, I. (1992). Social referencing, intentional communication, and interfacing of minds in infancy. In D.Frye & C. Moore (Eds.), Children’s theories of mind: Mental states and social understanding. New York: Plenum Press.

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Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press.

Chomsky, N. (1975). The Logical structure of linguistic theory. New York: Plenum.

Chomsky, N. (1986). Knowledge of language: Its nature, origin and use. New York: Praeger.

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Densmore, A. (2000). Speech on location: A Narrative play technique to teach expressive language and communication to children with PDD/autism/language delay. Journal of Developmental Learning Disorders, 4, 2, 209-239.

Emias, P.D., Siqueland, E.R., Jusczyk, P., & Vigorito, J. 1971. Speech perception in infants. Science, 171, 303-306.

Gee, J.P. (1985). The Narrativization of experience in the oral style. Journal of Education, 167, 9-35.

Gleason, J.B., & Ratner, N.B. (1993). Psycholinguistics. Orlando, FL: Harcourt Brace.

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Golinkoff, R.M., Mervis, C.B. & Hirsh-Pasek, K. (1994) Early object labels: The case for a developmental lexical principals framework. Journal of Child Language, 21, 125-155.

Golinkoff, R.M., Hirsh-Pasek, K., Mervis, C.B., Frawley, W.B. & Parillo, M. (1995). Lexical principles can be extended to the acquisition of verbs. In M. Tomasello & W.E. Merriman (Eds.), Beyond the names for things, Young children’s acquisition of verbs. Hillsdale, NJ: Erlbaum.

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McCabe, A. and Bliss, L. ( 2003). Patterns of narrative discourse. Boston: Pearson Education Inc.

McCabe, A. and Peterson, C. (1991). Developing narrative structure. Hillsdale, NJ and London, England: Lawrence Erlbaum Associates, Publishers.

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Murphy, C.M. & Messer, D.J. (1997). Mothers, infants, and pointing: A study of gesture. In H.R. Schaffer (Ed.), Studies in mother-infant interaction. London: Academic Press.

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Cambridge, MA: Harvard University Press.

Wetherby, A. & Prizant, B. (2000). Autism Spectrum Disorders–A transactional developmental perspective, Baltimore: Paul Brooks Pub. Co.

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Ann Densmore, Ed.D., CCC SLP/A
Child Talk 4 Militia Drive Suite 15
Lexington, MA 02420 (617) 497-9222
ann_densmore@post.harvard.edu

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