**5. Play in occupational therapy**

Besides being an activity that exists in every stage of life, play is the most proper way for a child to learn the world he/she lives in and to express emotions such as happiness, anxiety, and joy particularly during the first years of life. Bundy describes it as ''play is a transaction between an individual and the environmental that is intrinsically motivated, internally controlled, and free of many of constraints of objective reality'' [96].

Play is primer occupation of the child. Through play, children can gain developmental milestones, learn about occupational role, behaviours, and how to interact safely and appro‐ priately within their environment. Children with autism display atypical and insufficient play skills at different levels. This atypical and insufficient play skill is generally reported as playing with a toy stereotypically (rotating, shaking, sequencing, putting one on top each other) which is not suitable for its function, lack of social skill, flexibility and creativity skill to continue the play. Developments in symbolic activity, play and social relation areas observed in children younger than three years of age are not generally reported in children with autism [97]. Rare interaction of children with autism with their peers limits their attainment of playing in solitary and group plays with their peers [98]. Since game playing requires developed motor planning and praxis skill, this may result in child's showing motor planning and praxis during play [96].

**• Adaptation of task methods**

174 Autism Spectrum Disorder - Recent Advances

**• Visual Strategies**

**• Assistive Technology**

**• Sensory Strategies**

"Grading" is a method commonly used by therapists. Grading is adaptation of task or parts of a task according to the capability of child. Activity is divided into subtasks with task analysis

Individuals with autism can process visual information easier than auditory information [89]. Visually based interventions include visual (e.g., picture, written) schedules, visually organ‐ ized tasks, written or pictorial scripts, rule reminder cards, and visual task analyses [90]. Such interventions are reported to be effective in individuals with autism [90, 91]. These activities may be used for individuals with autism to learn activities of daily living skills, to foresee daily

In literature, technologies like video modeling, video prompting, handheld devices, structured computer games and virtual reality environments are used for training purposes. Research incorporating technology has consistently demonstrated good effects to daily living skills for children with autism. Additionally, assistive technology requirement of occupational thera‐ pist, which technological tool is applicable and proper assessment of factors related with

Creating sensory-friendly environments and implementing adaptive sensory strategies are important for effective ADL and IADL performance in children with sensory modulation problem. For instance, environment should be structured to be silent when an activity is performed with a child who has auditory-hyperresponsiveness responses. Use of earphone is recommended in environments that cannot be controlled. Another example is that preparation of a child with deep pressure and organized, rhythmical touches might be facilitating before

Besides being an activity that exists in every stage of life, play is the most proper way for a child to learn the world he/she lives in and to express emotions such as happiness, anxiety, and joy particularly during the first years of life. Bundy describes it as ''play is a transaction between an individual and the environmental that is intrinsically motivated, internally

Play is primer occupation of the child. Through play, children can gain developmental milestones, learn about occupational role, behaviours, and how to interact safely and appro‐ priately within their environment. Children with autism display atypical and insufficient play skills at different levels. This atypical and insufficient play skill is generally reported as playing

accessing technology such as economical status of family are important [92-95].

and task is modified depending on the difficulty or easiness level for the child [78].

routine and to become independent from various environments [92].

starting a dressing activity with a tactile defensive child [23].

controlled, and free of many of constraints of objective reality'' [96].

**5. Play in occupational therapy**

Occupational therapists are concerned with the occupation of play and the child develop‐ ing as a lifelong player [99, 100]. Providing engagement with play in children with autism is one of the most important parameters of occupational therapy interventions [101]. The primary goal of occupational therapy interventions in children with autism is to ensure attainment of motor planning and praxis skills, which will improve child's concrete thinking and play setting skills [99-101].

Play is multidimensional phenomenon that includes entertainment, spontaneous problem solving skill and creativity and requires collaboration of different disciplines [101-103]. Engagement in play and sustainability of play continue as long as the self-motivation and creativity of the player continue. Active engagement of children with autism in play and sustainment of play with adaptive response is one of the most important objectives in occu‐ pational therapy interventions [96, 99-101].

Our senses (tactile, visual, auditory, olfactory, gustatory, proprioceptive and vestibular) help us to collect information from the environment we live in and provide that we give adaptive responses suitable for the environment and we generalize what we learn. Sensory information is effective in the establishment of body scheme, which is one of the most components of motor planning skill [13, 104-106]. Studies reported that integration of tactile, visual, proprioceptive and vestibular sensory inputs offer improvement of body-spatial awareness [106-108]. When children with autism fail to produce adaptive response suitable for their environment and have insufficient body scheme, such may lead to negative experiences in their occupational performances and may result in anxiety, frustration, anger and avoidance [109]. Therapeutic play used in occupational therapy intervention can lead the child into a motivating activity with inner drive that encourages active movement, self direction, interaction, sensory building blocks and help addressing occupational performance and occupational profile of the child with autism [106, 109]. A study assessing the effectiveness of play therapy in literature reports that DIR-Floor Time and similar developmental approaches have a positive impact on emotional functioning, communication, and daily living skills and moreover creates positive changes in parent-child interactions [110]. It's noted that play based occupational therapy improves motor and social skills in children with developmental delay [111]. Hebert reports in his study that therapeutic plays practiced for children with developmental delay in line with their occupational frameworks improve their non-verbal and verbal communication skills [112]. As noted by such evidence-based studies, well structured play which is commonly used in occupational therapy interventions has a positive impact on motor skill and planning, communication-interaction and social skills of children with autism.

#### **5.1. Assessment**

Play is what children to do and they expend considerable social, cognitive and motor resources while playing, therefore play assessment may provide very meaningful insights about a child's interests, functional abilities and behaviours [113-115]. The selection of a play assessment will vary depending upon the developmental status of the child, the purpose of the assessment and the intervention plan. Test of Playfulness [114], Knox Preschool Play Scale [115], Play History [116-118] and Trans-disciplinary Play-based Assessment [119], My Child's Play [120, 121] tests are among the common standardized tests used to plan occupational therapy interventions for the improvement of play skills [117]. Furthermore, occupational therapists frequently refer to Observations of Factors Influencing Playfulness Form [121, 122] to plan their interventions.

#### **5.2. Intervention**

Occupational therapists frequently use sensory integration framework where sensory differ‐ ences of individuals are taken into account in improving play skills of children with autism. Developmental approaches like Dr. Stanley Greenspan's "Floor Time" method which aims to turn the relation between children and their families into a play with mutual interaction that contains trust and pleasure and philosophy of "Follow the child's lead" [123-126]. Addition‐ ally, virtual reality studies are also included under play interventions [127]. During occupa‐ tional therapy interventions, in addition to therapeutic use of play, occupational therapists play an effective role in the organization of play environment and parent education with the consideration of developmental level, challenges and strengths of child [128].

It's important for the occupational therapists to implement therapy programs designed according to sensory integration framework, under the leadership of child in structured environments for the improvement of motor skill, social-emotional well-being, cognitive process, praxis, attention, intimacy, interaction expression, use of feelings/ideas and logical thinking development of child with autism in play based occupational therapy interventions [129].
