LEGO therapy and autism: everything is awesome?

'Everything is awesome' (that's awesome not 'awsome') went the very catchy tune accompanying the LEGO movie not so long ago. Given the popularity of those colourful interlocking plastic bricks down the years, it was perhaps unsurprising that the film did so well and with the promise of more to come.

Aside from helping to influence generations of would-be engineers and dreamers (a double-decker couch?), LEGO has also found something of a following in relation to labels like autism (see here). Perhaps also why games such as Minecraft have 'taken off' with autism in mind, is the very 'systemising-based' principles behind LEGO and how, minus sweeping generalisations, autism and systemising have some research history (see here).

A recent paper by Helen Peckett and colleagues [1] adds to the small but emerging peer-reviewed research base looking at LEGO and autism, and specifically the idea that: "findings are supportive of previous Lego Therapy studies and have implications for strengths-based service provision." Peckett et al actually explored "mothers' experience of implementing Lego Therapy at home within the family" within the context of paediatric autism. Rather than assessing the intervention in a clinical trial manner (i.e. randomised, placebo-controlled, etc. study) the onus was on what mums of children with autism actually thought about the use of LEGO therapy. I know to some people this might seem like 'fluffy science' but in the context of a heterogeneous label like autism, I do think there is place for such research. More so when such intervention is designed to be carried out in the home environment with parents and siblings as intervention deliverers.

Suffice to say that much of the maternal discussions about LEGO therapy were quite positive in line with previous findings [2] and not just in the short-term [3]. As per the title of the paper, family relationships were a winner following the intervention, probably as a consequence of the greater involvement between mother and child (and siblings) in line with other reported findings (see here). There were however some fairly down-to-earth comments made about the intervention during the "interpretative phenomenological analysis" not least about "the impact of the intervention in the wider context." In other words, whilst LEGO therapy (or just playing with LEGO in a more structured way) may indeed have some value in terms of social skills such as sharing and turn-taking for example, how does this translate outside of the LEGO therapy context?

Similar questions could probably be asked about the use of Minecraft and related platforms too, bearing in mind how such 'gaming' probably does little to address important issues such as the promotion of physical activity for example [4] and the benefits that sports can potentially bring to some of the autism spectrum. That screen time might also have a negative side in terms of self-reported inattention in other groups [5] is something else to consider, as are other reports in the peer-reviewed literature [6].

By saying all that I'm not trying to poo-poo LEGO or Minecraft; I'm just saying that outside of being recreational activities, one has to be a little guarded about turning every play and leisure activity into 'therapy'. I might also mention how addictive LEGO and/or Minecraft can be; something which I assume can be as much of an issue for parents of children on the autism spectrum as it is for everyone else when it comes to getting children on to other tasks. Oh, and LEGO certainly isn't cheap either...

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[1] Peckett H. et al. Maternal experience of Lego Therapy in families with children with autism spectrum conditions: What is the impact on family relationships? Autism. 2016 Feb 5. pii: 1362361315621054. 

[2] Owens G. et al. LEGO therapy and the social use of language programme: an evaluation of two social skills interventions for children with high functioning autism and Asperger Syndrome. J Autism Dev Disord. 2008 Nov;38(10):1944-57.

[3] Legoff DB. & Sherman M. Long-term outcome of social skills intervention based on interactive LEGO play. Autism. 2006 Jul;10(4):317-29. 

[4] Bremer E. et al. A systematic review of the behavioural outcomes following exercise interventions for children and youth with autism spectrum disorder. Autism. 2016 Jan 28. pii: 1362361315616002.

[5] Montagni I. et al. Association of screen time with self-perceived attention problems and hyperactivity levels in French students: a cross-sectional study. BMJ Open. 2016; 6:e009089.

[6] MacMullin JA. et al. Plugged in: Electronics use in youth and young adults with autism spectrum disorder. Autism. 2016 Jan;20(1):45-54.

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Peckett H, MacCallum F, & Knibbs J (2016). Maternal experience of Lego Therapy in families with children with autism spectrum conditions: What is the impact on family relationships? Autism : the international journal of research and practice PMID: 26851230

Toy preference and parent-infant communication?

I was intrigued to read the findings reported by Anna Sosa [1] who reported that "play with books and traditional toys was superior to play with electronic toys in promoting high-quality communication."

This was a study looking at communication between parents and their infants aged 10-16 months old as a function of toy type, where electronic toys - "3 battery-operated toys with buttons and switches that can be manipulated to produce lights, words, phrases, and songs" - were pitted against 'traditional' toys - "3 nonelectronic toys that also have the potential to teach animal names, colors, and shapes." Those electronic toys were also chosen on the premise that "they are marketed as educational toys that promote language development for children in this age range and are advertised as teaching animal names, colors, and shapes."

Describing results from 26 parent-infant dyads whereby pairs "engaged in 2 15-minute play sessions per toy set over a 3-day period" using electronic toys, non-electronic toys and also books (y'know those paper things), various outcomes were measured including child vocalisations, adult words and conversational turns. As per the opening sentence, toy type did seem to affect communication between parent and child. So: "Play with electronic toys is associated with decreased quantity and quality of language input compared with play with books or traditional toys." The author goes as far to say that set within other research in this area: "both play with traditional toys and book reading can be promoted as language-facilitating activities while play with electronic toys should be discouraged."

Being careful not to fall into any sweeping generalisations about how technology is 'all bad' for child development and beyond, bearing in mind where such discussions have previously led, I have to say that it there may be some important lessons to learn from the Sosa study results. That early years communication between parent and child is increasingly being realised to be pretty important is one part of discussions (see here for more information on the '30 million word gap' for example). That parents are also literally bombarded these days with various edu-toys and other gadgets often making some rather big claims is another aspect. The Sosa results hint that there might be a happy medium to strike between the old and the new when it comes to early play and communication (including reading) and that we should as parents, perhaps be mindful that electronic toys with their lights, sounds and various educational claims might not necessarily trump something a little less flashy. Similar sentiments might also apply to more pathological states too [2].

Music: William Shatner sings er... well, not for the easily offended.

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[1] Sosa AV. Association of the Type of Toy Used During Play With the Quantity and Quality of Parent-Infant Communication. JAMA Pediatrics. 2015. Dec 23.

[2] Christakis DA. Rethinking Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr. 2016 Jan 4:1-2.

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Sosa AV (2015). Association of the Type of Toy Used During Play With the Quantity and Quality of Parent-Infant Communication JAMA Pediatrics : 10.1001/jamapediatrics.2015.3753

Pretend play and autism

A lightsaber in production @ Wikipedia

I'm leaving the heavy biochemistry of late behind in this post with a link to an interesting paper recently posted on Twitter by Prof. Graham Davey (Twitter: @GrahamCLDavey) reviewing the current evidence on the impact of pretend play on child development*.

To quote: "...existing evidence does not support strong causal claims about the unique importance of pretend play for development".

Whoa there... pretend play over just play might not be such a vital component to child development? Y'mean all those hours honing my Vader-like lightsaber skills with those stuck together toilet roll tubes were wasted?

On reading such a paper my mind almost immediately wanders back to autism and publications like this one from Christopher Jarrold** reviewing the pretend play research base in autism alongside quite a few hours learning about play - imaginative and/or pretend play - through schedules like the ADOS. Indeed, isn't a problem with imagination and, by inference, imaginative/pretend play supposed to be a key hallmark of an autism diagnosis separating autism from not-autism? That was one of the findings from the artificial intelligence boiling down ADI-R paper published recently. So logically, does this mean that an absence/limitation of pretend play in cases of autism might not necessarily have such dire consequences for future development?

OK, I don't want to get too carried away here on the basis of one review. Indeed even the lead author, Prof. Angeline Lillard in this media piece admits that whilst pretend play probably doesn't have the final say in aspects such as creativity and problem-solving, it might very well aid in skills like language and social development - both key points to diagnosing autism; indeed social affect rolled into one according to the DSM-V suggestion. She also notes the very fuzzy issue in linking how specifically pretend play contributes to child development independently and outside of all the other factors which combine in that process called growing up.

It does however make me wonder whether the rigidity with which psychology has seemingly applied the importance of pretend play both in the context of autism and more generally in child development has been 'overstated'. Indeed, if we go back to the pretend play -- perspective-taking link as described by articles like this one by Doris Bergen*** for example, which makes mention of Theory of Mind (ToM), it makes me also wonder whether one could also question the global importance of ToM for 'proper' development too?

Individual differences? Compensation strategies? Have I said too much? Should I perhaps also not mention the recent paper by Sachse and colleagues on executive dysfunction and (adult) autism****?

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* Lillard AS. et al. The impact of pretend play on children's development: a review of the evidence. Psychological Bulletin. August 2012.

** Jarrold C. A review of research into pretend play in autism. Autism. 2003; 7: 379-390.

*** Bergen D. The role of pretend play in children's cognitive development. Early Childhood Research & Practice. 2002; 4.

**** Sachse M. et al. Executive and visuo-motor function in adolescents and adults with autism spectrum disorder. JADD. September 2012: PMID: 23011252

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Lillard AS, Lerner MD, Hopkins EJ, Dore RA, Smith ED, & Palmquist CM (2012). The Impact of Pretend Play on Children's Development: A Review of the Evidence. Psychological bulletin PMID: 22905949