Play simple and straightforward, it is a complex

Play therapy is a psychotherapeutic method used by therapists primarily for children aged 3 to 12 years old. Play occurs naturally in most children. Although it seems simple and straightforward, it is a complex phenomenon that allows children to move through several developmental stages and develop intricate social attributes such as imagination, creativity and complexity into their actions and thought processes (Mastrangelo, 2009). Mastrangelo (2009) defines play as the following: • It is a “pleasurable and enjoyable” activity;• There is no end goal subscribed by external parties;• It is unplanned and “intrinsically motivating”;• It requires the players to be actively engaged;• The process is prescribed greater importance than the end product/goal of the activity or action;• It is “flexible and changing”;• There is no linearity in its progress.During play, children are engaged with objects and/or other individuals, therefore creating opportunity for interaction where they learn to prescribe and subscribe meaning to their actions or words (Morgenthal, 2015). Wolfberg (as cited in Morgenthal, 2015, p. 21) states that children learn about their individual self and of others: their emotional state of mind, making sense of the world, and learning to navigate oneself successfully in this process; the relatedness to others is being developed through the play process. Tuber (as cited in Morgenthal, 2015, p. 21) reports that children experience various situations while engaged in play: solitude, togetherness, being part of the play world, simultaneously aware that one is in the play world, but also part of reality. In addition, children recreate past experiences and interactions with others, evoking emotions that they are familiar with. They do not create new scenarios to discover new affect. Thus, the meaningfulness behind play is infused by the child’s creativity and past experiences. Play “encourages cognitive enrichment, emotional growth, and influences personality development” (Lantz, 2001). It is, thus, an important social and cognitive activity that is a precursor to a healthy development of a child. One of the hallmarks of children with autism is that there is a persistent deficit in social communication and social interaction across various contexts such as school and home. The deficits are not accounted for by general developmental delays. These deficits are manifested in three ways: 1) deficit in social emotional reciprocity, 2) deficit in non-verbal communicative behaviours used, 3) deficit in developing and maintaining relationships. They experience difficulties in three main areas, also known as triads of impairment: social communication, social imagination and social interaction. The Centers for Disease Control and Prevention CDC (2017) has provided a list of symptoms that are commonly found in children with autism. Some of the symptoms of interests are: • Not pointing at objects to show interest by 14 months• Not playing “pretend” games (pretending to “feed” a doll) by 18 months• Preference to be alone and avoid eye contact as much as possible• Having trouble understanding other people’s thoughts and feelings or to vocalise their own thoughts and feelings• Have obsessive interests, do not share interests with others• Interactions are initiated to achieve desired goals• Facial expressions are flat or inappropriate• Physical contact is not appreciated• Repetitive behaviours or vocalisationAs such, children with autism are observed to engage in repetitive play patterns. They are inflexible in thoughts and actions, and tend to view the world in literal and concrete terms (Lantz, 2001). They are often thought not to have the ability to engage in creative thoughts and symbolic play. They are observed to be lacking in interactive behaviours with others. Playing alone is preferred. Even if there may be spontaneous play, it usually does not last long (Morgenthal, 2015). Correspondingly, they do not play well on their own, as compared to same age neurotypical children, nor with others for they do not possess the social scripts to engage with others meaningfully (Lantz, 2001). This then result in subsequent peer exclusion as other children do not know how to interact with children with autism without feeling excluded (little response from children with autism), or triggering them off (temper tantrums from children with autism due to their inflexibility). Such results are not desirable in the development for children with autism. Play therapy, thus, uses this vital activity to engage children who may have been compromised in their social-cognition skills to build a therapeutic relationship. It creates a safe and secure environment that children can be self-directed in their play activity (how to play, choose the toys to play), giving them the opportunity to “process their problems at their own pace, understanding and ability” (Gan, 2016). Because of its nature, play therapy also allow children with limited verbal ability to express their thoughts and feelings through the various experiences they have encountered, without fear of consequences. Warber (n.d.) listed out how play therapy can assist children in the therapeutic work:• To learn about their emotions• To learn how to communicate with others• To improve problem solving• To learn how to deal with behavioural problems• To learn to develop coping mechanisms of their comfort levelMayseyk (2016) explained that there are several patterns of play:• Attunement play: the basic foundation for play and involves a ‘to-and-fro’ interaction between the two parties (child and therapist). Emotional regulation is developed and supported through this form of play. Children with autism can learn to social skill such as eye contact, turn taking in conversation.• Body play and movements: involves gross motor skills such as jumping, climbing, crawling and leaping. Such movements prepare the brain and ready the child for unexpected and unusual circumstances. It is noted that children with autism often do not engage in such play frequently, because of the unpredictability nature of the movements.• Object play: approaching objects in different manipulative manner, such as banging toys. Sound problem solving skills are developed through this play. • Social play: this encourage the “development of social awareness, co-operation, self-esteem and pride”. It involves actions such as rough and tumble play, and celebratory play. Again, such play allows children with autism to partake in social settings with more ease.• Imaginative and pretend play: The underlying theory behind this play is the theory of mind, where the players assume a state of understanding for the assumed role. It generates creativity and trust between the players. Some play includes: playing house, doctors. • Narrative play: it involves activities such as storytelling, or reading together. This allows the child to develop the ability to reorganise his experience and make sense of the world. Hence, there is a wide array of learning and intervention opportunities for children with autism when their intervention programme is cooperated with play therapy.There are several approaches to play therapy with regards to intervention for children with autism and they are the Developmental, Individual, Relationship-based (DIR) Model, which was developed by Stanley Greenspan in 1989, the Integrated Play Group (IPG) Model, which was developed based on the Lev Vgotsky’s Social Constructivist theory (Lantz, 2001) and lastly, Child-centred play therapy (CCPT), which was developed based on the humanistic approach of Carl Rogers (Morgenthal, 2015).Under the DIR model, a framework is created to understand the “functional emotional development and unique profile of very child, and a guide to create emotionally meaningful learning interactions that promote critical functional emotional developmental capacities” (Lal & Chhabria, 2013, p. 697). There are six milestones for parents and professionals to take note of, namely: Self-regulation and interest, Intimacy, Two-way communication, Complex communication, Emotional ideas, and Emotional thinking. The DIR model focus on creating strong foundations for “social, emotional, and intellectual capacities” (Lal & Chhabria, 2013, p. 697).  A key to the DIR model is floor time. The child being the director of the play is an essential element to floor time. The session is usually held in a naturalistic environment. Therapists and parents will have to settle down on the floor and play with the child (Lal & Chhabria, 2013). Floor time allows perseverative play to be transformed into a behaviour that carries meaning and is developmentally beneficial the child, while also allowing relationships to be formed between child and others. As the child takes the lead during the play session, the adults must take note not to consciously teach skills, which the child may not be ready to be taught (Lantz, 2001). There have been reports that the DIR model has achieved significant improvements in areas such as affect, social behaviour, cognitive skills, symbolic play, and creative behaviour for most children who had undergone this therapeutic treatment (as cited in Lantz, 2001; Lal & Chhabria, 2013). The rationale behind the IPG model was to provide children with autism to play with neurotypical peers; there is a dearth of opportunities where such interaction can occur in naturalistic environment. Research have shown that active participation of children with peers can bring about benefits that cannot be replicated from children-adult interaction. Between themselves, children can create together shared social and imaginary worlds, where they are able employ skills, values and knowledge learnt from their society and culture. Similarly, when children with autism play with neurotypical children, the transactional experiences will allow children with autism to reap comparable benefits of play (as cited in Wolfberg, Bottema-Betuel, & DeWitt, 2012). The IPG model differs from the DIR model, whereby capable peer play partners (expert players) are introduced into the play session with children with autism (novice players). The session is facilitated by a qualified adult (IPG Guide), which can include a variety of professions – teachers, psychologist, therapists. The sessions are guided, until the children display competency in carrying out the play sessions on their own. During the play sessions, the IPGs take the opportunity to tackle the challenges (the triads of impairment) faced by children with autism, while building meaningful relationships between them and the neurotypical peers. Additionally, the model places importance in helping children with autism to develop an intrinsic desire to initiate play.  Wolfberg and her colleagues (2012) reported that the model has allowed children with autism to make significant progress in social and representational play, and that the gains can be generalised across partners and settings. It is reported that such gains can be measured qualitatively and quantitatively. Through authentic and inclusive social play sessions, children with autism can grow into individuals who show remarkable progress from their classical impairments. The CCPT model is a relationship-based intervention, where the child with autism form a close relationship with the therapist progressively through the play sessions. By creating a close and secured relationship, the child is subjected to an environment where he/she can engage in child-directed play and communication, and is accepted unconditionally, therefore creating a positive loop of self-enhancing acceptance. CCPT is not about ‘training’ children with autism to play, but encourages and affirms them to explore and discover their own mode of playing. They are not hurried to do anything, and can progress at their speed. In the meanwhile, communication skills are developed. The therapist uses the relationship as a lever to help propel the child to progress further; it is the therapist who is entering the child’s world, rather than the child having to fit himself/herself into the adult world. The nature of CCPT does not require the child to interact with the therapist, although the therapist can engage with the child through verbal and non-verbal reactions, a reflection of the displayed behaviours and communication. Through modelling, the child with autism is given tools to communicate in the way most comfortable for himself (Morgenthal, 2015).  Morgenthal (2015) reported that due to the little research done on CCPT for children with autism, there has yet to be conclusive reviews to be found. However, positive findings have been reported on case studies where researchers had found child-client to be responding positively to CCPT.  While these are only three approaches to play therapy, they aim to target the core challenges faced by children with autism, namely the triads of impairment in social communication, social imagination and social interaction. These approaches help the child develop coping mechanisms and skills, while also work to change impairments (rigidity and repetitive behaviours) that will hinder their progress in society. It is commendable that the therapeutic work appears to draw from various school of thoughts to address the challenges faced by children with autism. As there are directed play therapy and non-directed play therapy which parents can choose from, should parents choose to engage in play therapy, they are able to find one that suits their child’s temperament and style of play. Although there have been increasing research on the benefits of non-directed play, I believe that directed play still has its place in the therapeutic work, as different set of parents have different beliefs in their approach towards therapy.I am particularly interested in the IPG. I thought that the rationale of having peers to play together in a therapeutic setting is a very good way to introduce social interaction and settings to children with autism, as this allows them to transfer the skills and values that are learnt in the treatment easily beyond clinical settings. After all, they will spend most of their younger years with individuals primarily of their own age. Because of their social impairment, they may face a fair amount of social isolation and exclusion, yet this will perpetuate a negative loop of low self-esteem and confidence. To be able to learn social skills in a protected environment with peers who accepts them and be patient with them will surely be a boost in confidence for them. Also, there is a step where neurotypical children attend education sessions to demystify their perceptions on autism. I believe this step is crucial in pushing for future wider acceptance for children with special needs; they are after all like everyone who yearns for love and belongingness. However, I do think that adults/facilitators will still need to keep an eye on the neurotypical children, even though they may be trained, as they are still children who have yet to mature in their thinking and emotional control. It is heartening to know that Wolfberg and her colleagues (2012) are adapting the IPG for older age groups, drawing on past success in the children age group, as they receive validation for their underlying hypothesis that “social competence develops from authentic social experiences” (p. 74). However, one criticism of play therapy is that children with severe autism may not be able to participate in such a programme fully, especially so if they are non-verbal, non-communicative and only willing to engage in preservative behaviours. Play requires the child to interact in one way or the other, regardless if the therapist is fully engaged or merely sitting at the side to watch. Nonetheless, play allows a child with autism and his/her support group to explore various mode of therapeutic work, to develop skills and coping mechanisms necessary to cope with adult life. Play opens “areas of development and attempts to expand them” (Mastrangelo, 2009, p. 43). It also creates the opportunity for a meaningful and positive relationship, sorely lacking in most children with autism, to bloom between the child and the therapist/caregiver. The overall goal for any therapeutic work is to allow children with autism to generalise the skills they have learnt through therapy to a variety of contexts and people. When used appropriately, after considering their developmental needs and the social contexts which they are in, play and play therapy are powerful tools to help children with autism to overcome the classic challenges they face.