Professional Documents
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Youth Mental Health, CSSS de la Montagne (CLSC Parc Extension), 7085 Hutchison Room 204.2, Montreal, QC, Canada H3N 1Y9
Department of Creative Arts Therapies, Concordia University, 1455 de Maisonneuve Blvd. West, SVA 264, Montreal, QC, Canada H3G 1M8
c
Division of Social and Cultural Psychiatry, McGill University, Canada
b
a r t i c l e
i n f o
Keywords:
Sandplay
Play
Autism spectrum disorders
School-based interventions
Action research
a b s t r a c t
A school-based action-research intervention with children with autism spectrum disorders investigated
whether sandplay could be used as a medium to stimulate creative and symbolic play. Twenty-ve elementary school children in four separate special education classes within the regular school system
participated in sandplay workshops once a week for 10 sessions. The intervention aimed to stimulate
communication, social interaction, and symbolic play through the use of rhythm- and movement-based
rituals and sandplay. Over the 10-week program, children demonstrated through sandplay increased
verbal expression, engaged and sustained social interaction, and increased symbolic, spontaneous, and
novel play. The study suggests that creativity-based interventions provide a complementary approach to
behavior/social skills-based intervention models prevalent in schools working with children with autism
spectrum disorders.
2009 Elsevier Inc. All rights reserved.
Introduction
The current practice of education of children with autism and
pervasive development disorders (PDD), or more generally autism
spectrum disorders (ASD), in Canada and more widely in North
America, has largely focused on integrating children into the mainstream education system, whether in special education classes in a
regular school setting or individual children integrated into regular
class settings (Brock, Jimerson, & Hansen, 2006; Bryson, Rogers, &
Fombonne, 2003; Hess, Hein, Morrier, & Michelle, 2008). Schoolbased education approaches for children with ASD demonstrate
a propensity towards highly structured behavior-based interventions, which have proven effective in addressing the core decits
in communication, social interaction, and restricted repertoire of
behaviors, activities and interests (Brock et al., 2006; National
Research Council, 2001). Although structured learning is essential
for this population to learn functional skills, proponents of developmental approaches contend that behavioral approaches are limited
in encouraging natural interpersonal interactions and spontaneous
symbolic play (Greenspan & Wieder, 2006, 2007). As spontaneous,
exible, imaginative, and social qualities of play are typically underdeveloped with children with ASD (Wing & Gould, 1979; Wolfberg,
1996), interventions that can promote this quality of play could be
benecial to children with ASD.
Corresponding author.
E-mail addresses: lucyluAT@gmail.com (L. Lu), ona.p@sympatico.ca
(F. Petersen), louise-lacroix@videotron.ca (L. Lacroix), cecile.rousseau@mcgill.ca
(C. Rousseau).
0197-4556/$ see front matter 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2009.09.003
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Storytelling
A storytelling period followed the sandplay activity for the more
verbally expressive groups of children. For the younger and less
verbal groups, limited verbal exchanges would be one-on-one with
the teachers or therapists, or occasionally children were invited
by the therapists to walk around and view the sandplay images
of their classmates, and to make one- or two-word descriptions
of their favorite objects. The more verbally expressive groups of
children were able to sustain enough attention to view and listen
to each of their classmates, as they either enacted or told their more
developed stories. In some instances, a few of the children chose to
work together to make collective sandtrays and stories.
The participatory nature of action-research encouraged the collaboration of teachers to modify the intervention to meet the
specic developmental and academic needs of the children. For
example one teacher structured the storytelling by asking the children to name the time, place, plot, and ending to their stories, while
another teacher contained the activity by holding up a 2-min timer.
The children appreciated the structure as it formalized the activity, providing them the undivided attention of their viewers. Many
children who appeared unfocused during their play made up stories
on the spot for their teachers and peers to appreciate. Regardless
of the changes or modications made to this storytelling section,
each class ended with the same closing ritual.
The closing ritual
The closing ritual remained constant and consisted of hand
clapping that mimicked the beginning, climax, and ending of a
rainstorm. Excess energy from the activity allowed an emotional
release through the dynamic physical movements at the climax of
the storm, while the slow mimicking of the patter of rain provided
a calming group experience that permitted transition back to the
regular school program. The children often requested to direct the
familiar activity themselves, which led to unforeseen offshoots of
the ritual, such as changing the rhythm, or adding different gestures or sounds, or adding their own personal touches such as the
sun coming out in the end. The closing ritual acted as a predictable
container to the creative space and, when it was child-directed,
it promoted self-esteem, group awareness, and the creative and
emotional investment that enhanced its appeal for the children.
Method
Action research
Following on previous research using sandplay adapted to a
school setting (Lacroix et al., 2007), in this research two art therapists implemented a creative intervention using sandplay and
interactive symbolic games. Action research is based on the premise
that research be conducted on real problems or issues faced by
practitioners in order to develop localized solutions (Stringer,
2007). In this case school teachers and psychologists working with
children with ASD in an integrated school setting expressed the
need to implement a more diverse range of therapeutic and educational practices that would meet the needs of children with
ASD. This research objective aimed to investigate whether creative interventions, such as the use of sandplay, could be used as a
semi-structured pedagogical tool that teachers could appropriate
in order to promote communication, socialization, and the capacity
to symbolize.
Population and setting
The children were a part of four special needs classrooms in
an elementary school setting in Montreal, Canada, designated for
children who met standardized criteria for autism and PDD. Each
classroom had 67 children, with one teacher, one special needs
educator, and occasionally a special education intern. The normal
ratio of adults to children in the class was approximately 13, while
during the intervention the ratio was 23.
Children participating in the program ranged from the ages of
712 years old, with an average age of M = 9.9 (N = 25), of which
23 were boys and 2 were girls (Table 1). Children were assigned
to their class according to age and developmental level. However,
even within these assignments, there was a large range of developmental expression within each class. In addition to the diagnosis
of autism or PDD, some children also demonstrated delays in
motor coordination and impaired hearing affecting elocution. This
French-speaking school was representative of an ethnically and linguistically diverse school setting in Montreal and, despite the small
numbers in these classes; the composition of the special needs
classes reected this diversity.
All parents consented to permit their children to participate in
the intervention and research. Most of the children participated
in the entire length of the 10-week program, with some absences
among six students for one to four sessions due to occasional sickness. On average, there was a 95% attendance of students to all of
the 10 sessions.
Data collection
Qualitative data were collected after each session following an
observation grid based on symbolic developmental levels of play by
Greenspan (Greenspan & Wieder, 2006) and grids of former sandplay projects by the team (Lacroix et al., 2007) (see Appendix A).
Observations of each child were noted for receptive and expressive
communication, social interaction, and symbolic expression during
all phases of the intervention. Children left the images intact after
each session and the therapists cleared the tray before the next
group. Photographs of each nal image of the sand tray were taken
along with particular reconstructions of images that were pertinent to the storytelling. As each child differed in their capacity to
express and communicate verbally the stories they created, observations were noted of their affect during play, level of engagement
with the materials, social interactions, and any verbalizations or
stories they made about their sandplay.
Teachers completed a questionnaire about their expectations of
the program and observations of the childrens symbolic capacity
Table 1
Categories of creative expression.
Creative expression
Sub-categories
3
4
3:0
4:0
89
812
8.7
9.8
6
7
5
5:1
7:0
4:1
710
712
1012
9.3
10
11.2
712
9.9
25
Age range
before the 10-week intervention. The two art therapists and the
psychologist met with the teachers at the beginning, middle, and
end of the program to gain feedback, share observations, and to
discuss the program. At the end of the program, a focus group was
held with the teachers by another member of the team.
Analysis of ndings
A content analysis (Stringer, 2007) was made of the data collected from the observation grids, the images of the sandtrays, and
the teachers observations. An initial global analysis of the program
was noted for the level of engagement of the children in the activity, the capacity to engage symbolically and the complexication
of stories over time. In the second level of analysis, children were
categorized according to similar descriptive developmental characteristics along the three dimensions of our study: communication,
socialization, and symbolic elaboration (see Table 1). The two subgroups that emerged from analyzing the production of the images
and the story progression were children that were characterized
by (1) pre-symbolic expression and (2) symbolic expression. The
pre-symbolic group was further categorized into two sub-groups
of tactile or sensorial exploration and functional play. The symbolic group revealed three sub-categories of rigid and ritualistic
play, beginnings of storytelling, and symbolic themes organized
into story form. From each group, an analysis was made of the
common developmental capacities and symbolic themes and tendencies demonstrated in the sand tray.
General ndings
The sandplay workshops appealed to the children, who manifested their appreciation by participating with enthusiasm, joy and
pride in both the rituals and the sandplay activity. Their teachers reported that they anticipated and talked about the workshops
several days in advance.
Within the 10-week period of the workshops no negative or
regressive reactions, such as poor concentration or increased agitation in class following a session, were observed or reported by
the teachers concerning the childrens behaviour. It was possible to
note changes in the complexication of symbolic use in the sandtrays and the stories told, as well as improvement in the general
attention and participation of most children. For instance, several
highly avoidant children engaged in social play, others moved from
functional play to incorporating some symbolic representational
play, while others elaborated on their symbolic and imaginary play.
The rigid play of certain children began to demonstrate more exibility as new elements borrowed from other childrens sandtrays
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For over half of the sessions, Ryan politely rejected all attempts
to expand on his play and repeated back all that was said to him in a
quizzical way. He responded with mild interest when the therapist
mirrored his play and moved another bus following him in the tray.
An entry into his play happened when the therapist elaborated on
his school bus play by placing a house as a destination for the bus to
stop. Ryans attention was piqued only when a personal connection
was made as it was suggested that Ryan himself lived in the house
and would be picked up by the bus. When the therapist encouraged
him to look in the gurine bin for a suitable representation for his
school, he appropriately picked a very large house. Further elaborations stimulated his active participation, and spontaneous symbolic
representation manifested as Ryan, in a quick and excited manner,
picked out animal gures from the gurine bin and identied each
one as his classmates and special educator, placing them around
the school in his tray. His teacher mirrored his excitement as he
named the familiar people represented in his sandtray. This activity marked the beginning of Ryans spontaneous symbolic play, as
well as a signicant reduction of his echolalia during his play. In
the remaining sandtrays, Ryan began each sandplay with placing
the house, school, and bus in the sandtray. Non-prompted spontaneous symbolic play began to emerge in such scenes as the bus
being attacked by a giant crocodile, re trucks and remen being
added to the sandtray, skeletons being buried, and so on (Fig. 4).
Ryan was able to develop his play after making an initial emotional
investment that had personal resonance for him.
Symbolic expression
Emerging symbolic, ritualistic and rigid play
This category of emerging symbolic play (n = 6) illustrates a
group of children that display the rigidity and ritualistic play, or
what might be termed as perseverative play (Pilewskie, 2007), often
characterized in children with autism (Wolfberg, 1996). This group
of children often had a difcult time regulating their emotions and
their level of internal organization or disorganization was often represented in the sandplay image. For example rigidity and ritualistic
play was demonstrated by nearly identical placement of gurines
with a repeated set of actions or scripts in each session that had
little variation or exibility. Disorganization was apparent through
chaotic placement or randomly lling the tray full of gurines.
In terms of their level of communication, they would often
express their interest and engagement non-verbally and were able
to say a few words or a sentence to describe their image or story
when prompted. Interactions during the sandplay were limited
to a few exchanges, as it was difcult for the teachers and facilitators to nd a point of entry into the play or ask questions to
the child, because of the single-focused quality of the play. When
the therapist was able to enter into the play, such as playing the
referee in a scripted sports game, it was possible to use the play
as a form of emotional co-regulation. However, for all the children in this category, they were often quite social and expressive
during the opening and closing ritual, demonstrated by smiling,
making eye contact, and initiating appropriate answers to our interactive themes and imaginary play. In their symbolic expressions
they would create simple storylines and symbolic themes such as
aggression in a sports game, or nurturance through an interactive
scene of gurines set amongst home furniture and food; however,
no further verbal description would be made.
Vignette: Mario. Mario is a 10-year-old boy who appeared smiling,
content, and interactive with his peers, teachers, and facilitators,
especially during the opening and closing ritual. However, from the
rst session Marios play in the sand tray was characterized by rigid
placement of gurines between two goal posts playing sports.
Throughout the play he seemed to perseverate by remaining xed
and focused on placing his team of players in the tray. He would
not respond to prompts or questions, nor was he interested in the
sandplay images of his peers and would often resist nishing his
play by the end of the session. When he did respond to our questions
of what was happening in the tray he would say They are playing
sports (Fig. 5).
Mario would ritualistically repeat this play in every session,
gradually modifying the play by adding animals, cars, play money,
and ags in the tray, and often there were so many gurines that
more and more would be placed outside of the sandtray. Mario
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made attempts towards symbolic interaction by placing the gurines facing each other; however, his rigid play did not provide
him with the fulllment of symbolic engagement. Yet in the last
session Mario appeared to satisfy this need by uncharacteristically
asking to be placed in the spot of his friend George, with whom he
had interacted in the previous session. He imitated Georges play by
having the gurines bounce off the sides of the box like a wrestling
ring to attack each other, while also borrowing English phrases
from George, like excitingly calling out 1-2-3 and Oh my God
as the gurines would launch an attack. Mario began the sessions
playing in a ritualistic and rigid manner; however, he responded
to his desire for greater symbolic engagement through imitation
and borrowing another play script in order to move beyond his
perseveration in his play. Despite the repetition and rigidity of
his sandplay images, Mario demonstrated an untapped capacity
for symbolic expression and engagement in the play and would
have probably beneted from a longer series of sessions in order to
elaborate his play.
Symbolic representation and the beginning of storytelling
In this group of children (n = 7), the sandplay images are richer
in symbolic representation and through the process the children
began to demonstrate a better capacity to link elements into a
rudimentary storyline. They had varying degrees and capacities of
communication, some were able to verbally describe their sandplay
images in full or partial sentences with and without prompting,
while others would enact or play out their stories in their telling.
For the most part, the children in this group were able to interact
during the exercises and enjoyed telling and showing their sandplay stories to their peers at the end of the session. Three of the
children actively played in each others sandtrays and told stories together. Many of them would incorporate gurines or stories
that would be inspired from the exercises or from observing other
childrens story images.
The symbolic themes in the sandplay of this group ranged
in complexity and included age-appropriate themes of aggression/ghting/death/fear; accidents and rescue stories; sharing and
nurturance; repairing when characters were hurt; and activities
from their daily livesschool, eating, sports, and birthdays. In this
group there was a range of different intellectual abilities, which
reected the degree of complexity that children were able to produce in their symbolic play. The story telling was not always
coherently organized into a recognizable story format with a beginning, middle (conict/issue), and end or resolution, but the stories
would often closely approximate this format. This group of children would be able to respond to play invitations from their peers,
teachers, or facilitators with common shared meanings and to elaborate upon them to continue the play. Through the progress of each
session, it seemed that the majority of children were able to elaborate their play by adding more elements and investment in their
stories.
Vignette: Emile. Emile is an 11-year-old boy, who was timid, calm,
and attentive throughout the sessions, and who liked to engage in
the exercises and activities. He communicated, often with prompting, in short, concrete phrases, seemingly self-stimulating on words
at the end of his sentences that he would accentuate with an inection or repetition. In his rst and second session, he demonstrated
elaborated functional play when he lined up the houses around
the sandtray and repeatedly moved a school bus back and forth
on the L-shaped corridor he created (Fig. 6). He allowed the therapist to elaborate the game by adding a trafc light, but when asked
about his story, he said The school bus is making his rounds in the
neighborhood houses and would not elaborate further.
However, by the third week, a shift in Emile became evident as
he was inuenced by the imaginary play theme of animals in our
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opening ritual. He initially began playing with the school bus, but
soon became more invested in creating a forest scene of animals
and plants. Initially, he was very timid to tell his story, but with
prompting from his peers he proudly described his story image stating The sun and stars are looking at the springtime. There are birds
and caterpillars in the forest. There are birds in nests in the forest.
There is a y buzzing (making the sound). Although he repeated this
springtime image for another two sessions, it appeared that Emile
became more inuenced by the imaginary play in the rituals and
slowly began incorporating people and creating elaborated scenes
(Fig. 7). As his stories developed, Emile gained the condence and
desire to recount his stories, often going beyond the time limit available. By the end of the ten sessions, Emile was able to elaborate his
symbolic play by incorporating more interactive elements, while
also beginning to link them coherently into a storyline.
Symbolic themes organized into story form
This last category regroups children (n = 5), who demonstrated
the capacity to create spontaneous, complex scenarios involving
much detail, drama, and a mostly coherent storyline. Emotional,
concrete, and magical thinking were present in their sandplay.
Many themes were developed expressing loss, intrusions, competition, conict resolution, and the establishment of boundaries.
This group had a higher level of language mastery, and
expressed relatively coherent stories in complete sentences.
Although they had the expressive vocabulary to indicate emotions, such as fear or sadness, affect was rarely present in their
expressive tone.
As demonstrated in sandplay with children within other classroom settings (Lacroix, 2002), three children appeared to use
sandplay to work through personal struggles, such as difculties
at home, frustrations with physical limitations, or personal tension
with classmates.
of religious practices or preferred movies. The medium of sandplay allowed these higher-functioning children with autism a space
to interact and focus joint attention on a creative activity while
supporting and stimulating the symbolic interactions in their play.
Discussion
As pleasure and enjoyment are essential characteristics of play
(Wolfberg, 1996), it is noteworthy that the children with ASD who
participated in this program enjoyed the sandplay process. Indeed,
sandplay was originally devised as a safe, free, and unfocused
space for children to play (Mitchell & Friedman, 1994). As such,
sandplay, adapted as a semi-structured creative intervention for
children with ASD, provided a multi-layered support for play and
creative expression. The sand and the diverse array of gurines
supported sensory and symbolic play; the individual sandtrays
delimited a protected space; while social interaction and expressive
communication was encouraged through the sharing of gurines,
the imaginary play in the rituals, and the storytelling exchanges.
Within the structure and framework of the rituals and sandplay,
children were given a non-goal-oriented and creative space for
unstructured play that encouraged symbolic development at their
own rhythm. This is an important condition for supporting creativity that is absent in adult directed activities typically practiced
within programs for children with ASD in schools. This complementary space to the regular academic program allowed freedom
for children to return to sandplay images and themes on a weekly
basis without the expectation to achieve a set academic goal.
Children responded to this semi-structured sandplay activity
with initial tentative involvement, yet over the course of the 10
weeks the increased engagement and investment in the activity
supported their developmental skills in communication, socialization, and symbolic elaboration. Children tended to work in a spiral
rather than a linear fashion, staying with the same themes and
building and expanding, with growing exibility upon their play
capacities over the course of the program. Children could address
their particular limitations pertaining to the foundations of relating, communicating, and thinking (Greenspan & Wieder, 2006) that
had not been previously mastered, such as sensory exploration,
engaging and relating, sharing attention, and purposeful emotional
interaction.
It appeared that for the children in the pre-symbolic level of
expression, the sensory tactile aspect of the sandplay encouraged motor skills development and early social play, while also
encouraging emotional regulation. Therapists, teachers, and special educators played the role of supporting emotional regulation as
well as two-way engagement by enhancing and expanding on sen-
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