leterle 1 prospectus #222

Running heading: BENEFITS OF PLAY THERAPY 1
Title: Benefits of Alternative Therapies with Autistic Children
Christina Leterle
HS 4900 Capstone Seminar
Kennesaw State University

Table of Contents
I. TABLE OF CONTENTS
II. PROSPECTUS
III. LITERATURE REVIEW
IV. METHODOLOGY (Case Study)
V. FINDINGS
VI. DISCUSSION
VII. APPENDICES
VIII. REFERENCES

PROSPECTUS
Christina Leterle
HS 4900: Capstone Seminar

I. What are the benefits of Play Therapy in the Development of Social Skills of Children
with Autism?
II. Readers:
First Reader: Steve King, Ph. D, LCSW, KSU Professor
Second Reader: Sue Kizer, Academy Academic Advisor, The Kennesaw State
Academy for Inclusive Learning and Social Growth
III. Nature of Project: Research-Based
IV. Background and Significance:
 Children diagnosed with Autism Spectrum Disorder face developmental challenges
primarily with social, behavioral, and communication skills. Autism Spectrum Disorder
is classified under neurodevelopmental disorders. Those diagnosed with Autism
experience atypical developmental signs for social and language delays or impairments as
well as ritualistic behavior patterns. There is no known cause for Autism at this time,
which makes treatment plans difficult for these children and their caregivers. Treatment
for Autism is typically combined with therapy and medication in order to address the
behavioral problems such as anxiety and aggression. However, ASD requires
individualized treatment plans which leads to trial and error therapy techniques and
appropriate medications. Medications will help with symptoms but they do not correct all
of the behavioral problems or communication barriers. Social skills are taught through
societal norms and the child’s environment. A caregiver or a parent is meant to facilitate
in the understanding of appropriate and inappropriate social skills and remain consistent
in doing so. A child with Autism, depending where they are on the spectrum will not
always understand appropriate social skills and the importance of these skills evolving as
they grow. Play therapy focuses on a personality structure, which allows children to
interact in their own environment and allow the child to talk out their difficulties and

struggles in a less stressful setting. Play therapy involves non-directive and directive
therapy techniques.
V. Goal(s), Objective(s) and/or Research Questions
 The goals for showing evidence the alternative therapeutic processes such as Play
Therapy can help with the development of social skills in children who are diagnosed
with Autism. The objective would be to benefit those working with Autistic children and
not relying solely on academic or traditional methods of managing Autism. Those
working with these children would use a combination of therapies for the child and create
an individualized plan for that child. SMART goals – Specifically research the evidence
recorded from therapists using play therapy, non-directive and directive, and identify if
play therapy improved social skills for children with Autism. For example: Did the
evidence show that the ASD children were able to carry on conversations with other peers
or were these children able to verbally communicate what was bothering them through
the use of play therapy? Realist goals: Did ASD children retain the social skills taught to
them when play therapy was involved in their treatment plan. Timely goals: In relation to
my own case study, how long is needed to evaluate and analyze a child’s personality
structure.
 In this project the following will be explored:
- Play therapy benefits in Autistic children’s social skills
- Do human service professionals follow the academic origins of Play Therapy or
do they develop their own trial and error treatment plans depending on the child.
- Are all children on the Autism Disorder Spectrum the same in their development
of social skills, behavioral and cognitive processes?

 Research question: What are the benefits of Play Therapy in the Development of Social
Skills in Children with Autism?
VI. Methodology
 Case study in addition to a comprehensive exploration of the origins of Play Therapy in
relation to treatment of children with Autism.
VII. Literature Review
 Axline, V. M. (1969). Play therapy. New York: Ballantine Books.
 Bratton, S.,Ray, D., Rhine, T., & Jones, L. (Aug 2005). The efficacy of play therapy with
children: A meta-analytic review of the outcome research. Professional
Psychology: Research and Practice, 36(4).
 Gobrial, E., & Raghavan, R. (2012). Prevalence of anxiety disorder in children and young
people with intellectual disabilities and autism. Advances in Mental Health and
Intellectual Disabilities, 6(3), 130-140.
doi:http://dx.doi.org/10.1108/20441281211227193
 Drew, A., Baird, G., Baron-Cohen, S., Cox, A., Slonims, V., Wheelwright, S.,
Swettenham, J., Berry, B., Charman, T. (2002). A pilot randomized control trial
of a caregiver training intervention for pre-school children with autism:
preliminary findings and methodological challenges. European Child &
Adolescent Psychiatry, 11, 266-272.
 Hatamzadeh, A., Pouretemad, H., Hassanabadi, H. (2010). The effectiveness of
caregiver-child interaction therapy for children with high functioning autism.
Procedia Social and Behavioral Sciences, 5, 994-997.
VIII. Demonstration of Course Competencies:
 HS 4600 Working with Children and Youth – The student learned different interviewing
techniques when counseling children and adolescents.
 HS 3300 Human Socialization – The student learned the importance of social interactions
as we develop through life.

 HS 4500 Working with Families – The student learned the diversity within family
dynamics and the importance of teaching your children appropriate behavior in society.
IX. Detailed Work Plan:
 February 25- Capstone Prospectus due on D2L in drop box by 11:59. Class meeting on
February 25th.
 Week of 3/3/16- Begin working on three parts of the literature review: History,
Prevalence and Severity. Meet with Dr. King due to no class meeting.
 Week of 3/10/16 – complete the Literature Review for revision before the due date on
3/10/16 in turnitin.com for the first draft of the Literature Review. Class does not meet on
this date.
 March 17- Work on theory, practices and methodology for paper. Continue working on
assignments. Class does not meet this week.
 March 24- Work on Methodology and where to put personal case study and the
placement of the case study.
 March 31- No class meeting is taking place; sign up for weekly meeting with Dr. King for
revision and progress comments on paper.
 April 7th- spring break, campus will be closed. Continue to work through the tabs on the
paper.
 April 14th- Final paper and final presentations will be beginning. Writing the final report.
 May 2nd – Final Capstone project is due.
 May 4th- Capstone presentation at 1:00 – 2:00 with Dr. King and Sue Kizer.
X. Reference Page
 Refer to the Literature Review above.

LITERATURE REVIEW
Christina Leterle
HS 4900: Capstone Seminar

History
Autism Spectrum Disorder is categorized as a neurodevelopment disorder that affects the
individual’s social, behavioral and cognitive capabilities. Throughout the past 60 years, the
discovery of Autism has gained more recognition for being one of the most puzzling
neurological disorders without a known cure or cause for the disorder within individuals. As the
disorder continues to rise in people of all ages, a treatment for individuals with ASD has yet to
find a one size fits all treatment. (Sandler, et al. 2001). Studies from the Center for Disease
Control and Prevention currently estimate that 1 in 68 children have Autism Spectrum Disorder
in the United States. (Christensen, et al. 2012).
Leo Kanner is known to be one of the first psychologists to recognize the signs and
differences in Autism and Asperger’s. Kanner saw what behavioral issues first that he accredited
to developmental delays and contributing factors of autism (Kanner,1943). Kanner brought
awareness to the disorder, however the child psychiatrist accredited parental avoidance or
negligence toward the child as a dominating factor in children with Autism and their
development. Hans Asperger was the psychologist to discover the differences between Autism
and Asperger disorder characteristics. Hans Asperger was a pediatrician in 1944 that worked on
cases of “autistic psychopathy of childhood”. Hans Asperger is known for stating the following
research in relation to Autism findings, “They were often able, some with extraordinary gifts in
mathematics or natural science with creative, original modes of thinking and objective self-
appraisal. But their social and emotional relationships were poor,” (Frith, 1991). Autism is
known for communication delays and disorders, because of the speech problems associated with
the disorder. These two pediatricians’ are said to be major pioneers in the findings of the history
of Autism (Ratajczak, 2011).

However the difference between Autism Spectrum Disorder and Asperger’s is
predominately differentiated by the social interaction delays within these neurological disorders.
Individuals with Asperger’s often do not fall within the average IQ of 70 for those diagnosed
with ASD but these individuals with Asperger’s disorder have a lack in social skills and
communication. Autism Spectrum Disorder often exhibits more issues than just social interaction
issues.
History of Diagnosing Autism
Diagnosing Autism has no current official medical test; Autism Spectrum Disorder is
typically conducted through developmental screenings and comprehensive diagnostic
evaluations. Testing has proven to be more successful the older the child is because the behavior
and cognition is more developed therefore behavioral differences are more easily detected for the
professional or the parent (Center for Disease Control and Prevention, 2016). Primary care
doctors conduct screenings for any developmental delays and if any concerns arise then a
comprehensive diagnostic evaluation is conducted, this portion of the testing often involves a
child psychologist of some kind testing and observing the child’s behavior.
Refer to Appendix A, to see the Pediatric Developmental Screening Flowchart for children
who may be displaying developmental delays or concerns (“Identifying Infants and Young
Children With Developmental Disorders in the Medical Home: An Algorithm for Developmental
Surveillance and Screening “, 2006). The flowchart is broken down into steps, which first ask the
parent or guardian to answer questions about the child, which is then scored by the clinician.
After the clinician reviews the scores and the child tests positive for developmental delays then
the physician will suggest immediate action to be required with more testing. The provider then
discusses results and concerns with parents, performs more specific medical & developmental

assessment him or herself or refers the family to a therapist for a more in-depth evaluation.
However if the child screens negative, and there are concerns noted, the provider will annually
monitor the child at each visit and take notes and listen to any worsening behaviors that may
occur and this is called developmental monitoring or surveillance that is conducted by the
primary doctor.
Placing an average IQ on children with Autism has been difficult in the past due to the
individual factors that make up a person with Autism. However the typical IQ for a child is
around 70 (Interactive Autism Network, 2007). Autism is usually diagnosed when three common
characteristics are present. These characteristics then fall into a triad of deficits in the areas of
communication, socialization and interests or activities. Communication and social interaction
skills are usually needed for effective traditional verbal counseling sessions (Heflin, 2007).
According to The American Academy of Pediatrics, it recommends, “that all children be
screened for developmental delays and disabilities during regular well-child doctor visits at 9
months, 18 months, and 24 or 30 months of age. They also recommend that children be screened
specially for ASD at 18 and 24 months of age (3-4)” (American Academy of Pediatrics, 2013).
The American Psychiatric Association's Diagnostic and Statistical Manual, (American
Psychiatric Association, 2013) provides standardized criteria to help diagnose ASD, which
includes the following and is split based on severity:
A. Persistent deficits in social communication and social interaction across multiple
contexts, as manifested by the following, currently or by history.
B. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
C. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for
example, from poorly integrated verbal and nonverbal communication; to abnormalities
in eye contact and body language or deficits in understanding and use of gestures; to a
total lack of facial expressions and nonverbal communication.

D. Deficits in developing, maintaining, and understand relationships, ranging, for example,
from difficulties adjusting behavior to suit various social contexts; to difficulties in
sharing imaginative play or in making friends; to absence of interest in peers.
This is the diagnostic criterion for Autism Spectrum Disorder when not specifying about
the child’s current severity of the problems (CDC, 2015).
The criteria are then broken down into more in-depth questions based on severity. According to
the American Psychiatric Association, “Severity is based on social communication impairments
and restricted, repetitive patterns of behavior.” (American Psychiatric Association, 2015). The
severity of the symptoms are then further broken down, which includes:
A. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two
of the following, currently or by history (examples are illustrative, not exhaustive; see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor
stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal
or nonverbal behavior (e.g., extreme distress at small changes, difficulties with
transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same
food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong
attachment to or preoccupation with unusual objects, excessively circumscribed or
perseverative interests).
4. Hyper- or hyperactivity to sensory input or unusual interest in sensory aspects of the
environment (e.g. apparent indifference to pain/temperature, adverse response to specific
sounds or textures, excessive smelling or touching of objects, visual fascination with
lights or movement). (American Psychiatric Association, 2013).
This criterion is the most current diagnostic standard for professionals to follow when
diagnosing children above the age of three with Autism Spectrum Disorder. For children over the
age of three there are various screenings that are conducted both at home and by the primary
physician. The screening, PEDS, which stands for Parents’ Evaluation of Developmental Status,
is questionnaires, which are answered by the parent/primary caretaker and their concerns about
their child’s developmental. The parent answers are scored into the risk categories of high,

moderate, or low (Glascoe, 2003). Refer to Appendix B, which is an example of typical PEDS
questionnaires given by a pediatrician. When discussing developmental delays or concerns you
will often hear the following terms associated such as delayed development, disordered
development, and developmental abnormality. These terms commonly signify a child’s mental or
physical impairment or a combination of the two, which can result in substantial functional and
cognitive limitations in the individual’s life (Accardo, et al. 2003).
The Gilliam Autism Rating Scale is another scaled evaluation for diagnosing Autism.
This scale works off of a sum of standard scores and a percentile. The test looks at three main
areas that include: stereotyped behaviors, communication and social interaction. Refer to
Appendix C for an example of the Gilliam Autism Rating Scale for children being tested for
Autism (Pandolfi et al., 2010).
Over the years, several standardized testing, questionnaires and scales have been created
in the efforts to identify if a child is Autistic or has another neurological disorder based off of
developmental delays in cognition, behavioral issues or delayed social and communication skills
(American Academy of Pediatrics, 2006).
History of Play Therapy
Considering that traditional counseling requires the ability of the child to communicate
with a counselor, play and in particular sand play may be a more appropriate medium to express
their thoughts and feelings, and in a safe place develop problem solving skills (Parker et al.,
2011). Terminology associated with play therapy includes: person centered approach, play
therapy approach, floor time therapy, interactive play, the developmental individual-difference
relationship-based model and cognitive behavioral approach.

Play Therapy techniques became more popular after the author Virginia M. Axline
published her book about Play Therapy and case studies based on children with communication
disorders. The Play Therapy techniques she used were effective in the effort of getting children
to talk through a child’s natural medium, which is in the form of playing and self-expression. In
Virginia M. Axline’s book, Play Therapy, Play therapy is described as an opportunity, “ It is an
opportunity which is given to the child to “play out” his feelings and problems just as, in certain
types of adult therapy, an individual “talks out” his difficulties.” (Axline,1969, pg. 9). Axline
highlighted a need for a personality structure when using play therapy with children. In Axline’s
book, Play Therapy, she describes in the following excerpt the need for a personality structure in
the following paragraph, “ It is the purpose of this book to explain just what play therapy is and
to present the theory of personality structure upon which it is based, to describe in detail the
play-therapy set-up and those who participate in the therapeutic process, to present the principles
which are fundamental to the successful conduct of play therapy, to report case records which
show its effectiveness in helping so-called problem child to help themselves in making their
personal adjustments, and, finally, to point out the implications of play therapy for education.”
(Axline, 1969, p. 7).
Throughout Axline’s therapy sessions she made many points about therapy that cannot be
rushed when dealing with children. She expressed an understanding of the feelings of frustration
from the parents and wanting quick results when trying to “fix” their child. However, rushing the
therapeutic process could pose a real danger to the child and could lead to potential regression
and destruction of the trust and rapport building between the client and the child.

Non-Directive Approach vs. Directive Approach Therapy
Play therapy is often done through a non-directive approach or a directive approach. This
means that depending on the approach the therapist choses, the direction and responsibility is
either done through the therapist’s direction or left to the child or client’s direction for therapy.
Non-directive approaches in therapy aspire therapists to demonstrate their use of the core skills
of unconditional regard, empathy, and congruence, together with some of her skills in child-led
play (Rye, 2010). Examples of non-directive therapy approaches include: a child entering a room
and allowing the child to pick out of the playroom what activity he or she will be participating in.
It is a less structured form of therapy that is mostly led by the child and the therapist observes
and asks questions during the activity (Schaefer, 2013).
History of Causes or Cures of Autism
There is no current cure for Autism at this time, many believe it is due to genetics but
there is not evidence why causes Autism (Whitman, 2004). Andrew Wakefield claimed there
was a “link” between vaccines and claimed they were associated with the cause of Autism,
however, the doctor claims his results were based off of reports from parents’ with Autistic
children and not based off of his own scientific study about the link between vaccinations and
Autism Spectrum Disorder being a cause. The doctor’s scientific study and unproven claims
were discredited in 2007 (Kolodziejski, 2014). There are two medications available for treating
individuals with Autism however since ASD is a spectrum disorder, meaning all individuals with
ASD all struggle in different areas. Autism targets three areas of the brain’s functioning; social,
behavioral, and cognitive. Which makes finding a cause or cure difficult to pinpoint and treat.

Prevalence
The Autism and Developmental Disabilities Monitoring Network (ADDM) tracks the
prevalence of ASD among children. Prevalence describes a scientific number of people with a
disease or condition among a defined group at a specific period in time. For example, the
resulting number is usually expressed as a percentage or proportion of the defined group. The
CDC conducted a study to see the number of eight year olds in metropolitan Atlanta in order to
see how prevalent Autism diagnosis was within the community of these children (Heasley,
2016). “The rates of autism prior to 1990 were reported to be five per 10,000 children. More
recently, the rates were thought to be six per 1,000 children, but that may be low according to a
landmark study published this month in the Journal of the American Medical Association”
(Christensen et al., 2012).
In comparing children with ASD with children with developmental and/or language
delay; young children with ASD used less verbal and non-verbal requesting, responsive smiling,
responding to name, following pointing, looking to read faces and functional play
(Trillingsgaard, 2005). These symptoms are important in social interaction between other
children. The lack of communication abilities in Autistic children has been a contributing factor
in their problems associated with having heightened anxiety.
Severity
The negative consequences associated with Autism in children and how it negatively
affects the family members. The parent’s side often reaches feelings of frustration. Parents have
to go through several evaluations in order to figure out which treatment plan is right for their
child, along with the knowledge that there is no known cause or cure for this neurological
disorder at this time. Parents also face the trial and error struggles that go along with using

medications for the child. Parents who do decide to use medication only have two FDA approved
medications on the market that are meant for treating Autism Spectrum Disorder. The limitations
with medication are that Autism affects the brain differently in each individual and based on the
scores of diagnostic evaluations the individual is on a spectrum. The spectrum often will label
the individual as a high or low functioning individual with Autism based on their particular
scores and which characteristics are the most prevalent. Typical symptoms that are amongst the
spectrum include: no eye contact, not initiating play, behavioral outbursts, communication
problems, speech and language issues, not recognizing social cues, and not wanting to be
touched/minimal human interaction. Observation is typical with Autistic children because
initiating in play is not common. (Autism Speaks. Symptoms, 2016). Referring to Appendix D:
the illustration of the Venn diagram displays the many ways in which Autism can affect a
persons whole body, both physically and mentally. Autism Spectrum Disorder is under the
umbrella of neurological disorders but this disorder has several links to different disorders that
Autism can cause on the body. (Stevenson, et al., 2015) For example, attention-deficit
hyperactivity disorder, bipolar disorder and schizophrenia, sleep disorders, epilepsy, and autism
genes to increased risk for cancer, autoimmune disorders, heart disease and kidney problems.
A famous quote said by Stephen Shore says, “"If you've met one person with autism –
you've met one person with autism." (Autism Speaks, 2016). This quote is popular within the
Autism community because each diagnosis is individualized and catered to the individual and
treated for the individual. The following paper will explore the need for alternative therapies and
a highlight on using Play Therapy specifically. The purpose of this paper is to explore: What are
the benefits of Play Therapy in the Development of Social Skills in Children with Autism?

Methodology
The method of collecting data includes the literature review design method. The literature
review design addresses the following, “Survey of previously published literature on a particular
topic to define and clarify a particular problem; summarize previous investigations; identify
relations, contradictions, gaps, and inconsistencies in the literature; and suggest the next step in
solving the problem” (American Psychological Association, 2012).
“A case study is an idiographic examination of a single individual, family, group
organization, communication or society. Although case studies typically use observation modes
in their research approach, this is not what distinguishes a case study. Instead, case studies are
distinguished by their exclusive focus on a particular case (or several cases in a multiple-case
study) and their use of a full variety of evidence regarding that case, including, perhaps, evidence
gathered by quantitative research methods” (Rubin, 2005). The following methods and
techniques will be highlighted in this case study based on a three and half year observational
research with an Autistic child.
In efforts to protect the identity of the child, the following fictitious name “Sammy” will
be used throughout this case study. This case study will illustrate the benefits of a consistent and
stable relationship between the caregiver and a child diagnosed with Autism. The case study will
also explore the severity of the child’s symptoms and what therapeutic techniques were used to
help this child progress socially and behaviorally. This case study also shows the importance of
consistency and early intervention methods when developing a young child’s social skills that is
on the Autism spectrum scale.

Case Study: The child, Sammy (Background)
Sammy is an eight-year-old child in a public elementary school, living in an upper middle
class family, which includes his mother, father and older brother. Sammy has severe asthma and
peanut allergies. Sammy repeated kindergarten twice due to his delayed social skills and speech
issues. Sammy has been enrolled in speech therapy classes since he was four years old. At the
age of five, his primary physician suggested diagnostic testing due to the concern about his
social, behavioral and cognitive delays. Sammy completed three days of diagnostic tests with a
therapist. After the testing was complete, Sammy’s therapist diagnosed him with high-
functioning Autism Spectrum Disorder.
Sammy’s Symptoms
Sammy had difficulties making eye contact with familiar and unfamiliar individuals.
Sammy often had a glazed look over his eyes and when trying to communicate, he would often
become fixated on one thing and not hear anything said. This was the biggest complaint
Sammy’s parents had, his inability to listen or focus when being talked to. Calming mechanisms
became important when dealing with Sammy’s overwhelming anxiety and frustration. Sammy
has a slow to warm temperament and is not flexible when it comes to changes in his daily
schedule. He would often have emotional outbursts when he became frustrated and cry
hysterically. Sammy often misunderstood people’s tone of voice and facial expressions. If
Sammy thought you were upset, he would become anxious and begin to cry. Sammy did not
have the ability to communicate when he was upset, angry, sad, or frustrated. This
communication problem happened with peers at school, teachers, caregivers and his parents.
Sammy experienced panic attacks and repetitive behaviors when he became overwhelmed with a
situation as well.

The Relationship Between The Caregiver and The Child
The caregiver and the child were together daily for a span of three and half years. The
caregiver and Sammy spent 40 plus hours a week together and between 60-75 hours during the
summers. Over the three years, Sammy and the caregiver developed a consistent routine and a
close relationship and friendship. I was Sammy’s caregiver over this time period and shortly
after working with him, Sammy was diagnosed with Autism. Sammy having a slow to warm
temperament made the initial trusting caregiver and child relationship a lengthy process. The
relationship took approximately three months to develop into a trusting and comfortable
friendship for Sammy. As the caregiver, I was patient, empathetic, and caring towards Sammy
and understood this process cannot be rushed. Through many sessions of building trust and
rapport, Sammy began to express his various interests and hobbies. Most of the hobbies were
artistic outlets or learning and talking about animals, talking about these subjects were often the
most successful avenues when trying to speak to Sammy on difficult days or in general. Sammy
was unable to have play dates outside of school because they were too overwhelming and he was
unable to interact in conversations or play activities that children his age are typically able to
engage in.
Sammy and I began to develop signals when he was having a bad day with behavior,
social or school issues. Sammy would put his hands on his neck or around his ears if he wanted
to nonverbally express to me that he was having a difficult day. Typical nonverbal cues that
Sammy would display included: no eye contact with anyone including family or caregiver,
jumping in one place repeatedly, hysterical crying, placing items into a straight line such as food
and erratic breathing. If Sammy was hysterically crying, zero verbal communication would occur
and it could last for hours. When Sammy would stop verbal communication, this is when

creative trial and error therapeutic techniques and calming mechanisms began to become
important in developing Sammy’s communication abilities and social skill development.
When Sammy began to start having panic attacks they were generally brought on by
stressful social situations and misunderstanding schedule changes, this when then lead to Sammy
not focusing at all or minimal responses when asked a question. Sammy is on the high
functioning end of the Autism spectrum but heightened anxiety and frustration were ongoing
symptoms that worsened as he aged. Not only was aging a factor in Sammy’s case but the
inconsistency in his intervention and treatment plans was also an issue. Sammy’s parents were
not equipped to deal with Sammy’s panic attacks or worsening behavioral problems and he
would often be sent to time out as a punishment for not focusing or communicating. Sammy
would be sent to time out and have to sit in the corner until he was able to settle himself down.
Sammy would eventually become exhausted from crying and fall asleep.
As the caregiver, a certain degree of patience was required when dealing with Sammy’s
atypical behavior and outbursts. I tried breathing techniques to stabilize Sammy’s breathing
when he was crying hysterically and the parents were not home. When Sammy would cry
uncontrollably it could often be stopped if you sat on the ground with him, held him tightly and
said, “Breathe…1,2,3,4,5, okay try again, breathe and try to count to five by yourself this time.”
The parents did not try this method unless I was present or I would just go and sit with him
before he was sent to the corner and speak to Sammy in a very soft voice and tell him to look at
me and breathe in and out slowly.

Expression through “Art Therapy”
Sammy independently created “alone playtime”, which started out as interactive playtime
with the family or his sibling but then slowly regressed to just playing alone without any social
interaction. By the age of six, Sammy further progressed in withdrawing from any social
interactions with peers. Sammy’s heightened anxiety around new people and unpredictable
situations were crippling and a major factor as to why Sammy did not have peers inside or
outside of school to play with. Social skills and interacting with others needed to be worked on
and developed quicker than he was learning. As the caregiver this became the main focus in our
relationship. When Sammy was having a bad day, I would ask if he would like to try “art
therapy” and try to relax with art projects. Discovering Sammy’s interest in arts and crafts was
relatively easy; realizing that art could be as a useful tool in helping Sammy communicate after
an episode was a breakthrough in Sammy’s progression of social skills and development.
As I previously mentioned earlier, art, music, dancing and animals were Sammy’s
biggest interests. When caring for Sammy, doing activities associated with creativity would
consistently provide positive outcomes when trying to communicate with Sammy.
Sammy completed the picture shown in the Appendix E, art therapy techniques were used
in the effort to identify the issue upsetting Sammy and to open lines of communication. This
particular day, Sammy and I worked on the picture of the butterfly, I picked out the art supplies
we would be working with and let Sammy pick the color of the piece of paper and he decided to
draw animals this day.
Sammy was not speaking when he was picked up from school this day; he kept his head
down and did not break eye contact with his shoes for thirty minutes. As the caregiver, I tried to
speak to Sammy several times and ask him what was bothering him or if something happened at

school that day; both questions were not responded to. Instead of the normal routine, I gave
Sammy a snack and let him know that we would be doing “art therapy” today instead of
finishing homework directly after his snack. Sammy knew what “art therapy” consisted of and
then began to lift his head up towards me and ask If we could draw animals.
During “art therapy”, it would start out quiet and then I would typically show him
different art techniques with paint or pastels that could be used. Sammy would either ask me to
show him the art technique or continue working independently. After fifteen minutes, Sammy
would begin asking for my thoughts on his picture. This was usually the best time to start a
dialogue with Sammy. I always left the opportunity for Sammy to speak first and not pressure
him about what was bothering him.
Sammy drew a butterfly on this day and the caregiver asked him why he wanted to draw
that animal. The “art therapy” session went as following:
Sammy: Butterflies have wings and always have lots of butterflies around them, so that means
they must always have friends and someone to talk to.
CL: (Nodded) Butterflies always have someone to talk to? What makes you think butterflies
always have someone to talk to?
Sammy: Because butterflies have multiple friends and they never run out of things to say.
Sammy: (Sammy continued to draw) I don’t have people to talk to at school and no one seems to
want to play with me.
CL: Sammy, what makes you say the kids at school don’t want to talk to you?
Sammy: It’s probably because the words get stuck in my throat and I don’t know how to make
them come out of my mouth all the time. I think they get stuck in my throat and this is why kids
bully me, but I can’t help it when they get stuck there. It makes me feel frustrated.

When Sammy was explaining that words get “stuck in his throat” he uses his hands to place over
his throat in the shape of an X.
Sammy: (shakes his head as his hands are placed over his throat) they just don’t come out
sometimes.
Sammy begins to cry and ask if words ever get stuck in other people’s throat.
CL: Yes Sammy, sometimes words get stuck in our throats and it can make me frustrated but
there are ways to work through that. I sometimes get anxious around new people and I feel like I
cannot speak either but this isn’t a reflection on me as a person. Just like it isn’t a reflection on
you as a person.
Sammy: I sometimes wish it were easier for me to talk because I think I am very funny and fun
to be around.
CL: (laughing) You sure are a goofball Sammy, and everyone will see that but it may just take
time and some work on your part to try and be social with the peers you do like at school.
Sammy: Okay done! (Sammy lifts his picture and turns to show me) Do you see my butterfly? I
like their wings. Maybe someone will want to talk about animals with me. But we have to have a
good day first Miss Christina.
CL: Okay Sammy, we will have a good day. Can I see your red colored pencil? I can’t have you
drawing better than the art teacher! (Sammy and I laugh and smile)
Sammy jumps in my lap and helps finish my picture of a worm and tells me it is
“beautiful” “Art Therapy” was the term we made up when we were having bad days and it was
an opportunity available to me when I needed to try and resolve an issue that was bothering him.

Developing Social Skills (Developing Social Skills and Understanding Facial Expressions)
Sammy’s primary teacher began to notice Sammy’s issues when it came to initiating
playing with other children in his class or during recess. His teachers noticed this when he was in
Kindergarten for the first time. Sammy’s brother was four years older and was incredibly patient
and helped him when playing with other children in their neighborhood. Even a familiar
individual such as his brother would often leave Sammy standing by me and just watching the
other kids play. Sammy would just stand in one place on the sidewalk and watch the entire
neighborhood kids ride their bikes.
Initiating play was difficult for Sammy because he struggled with interpersonal skills. For
example, Sammy tried making up a game with other kids but there game he was attempting to
explain made little sense and the children began saying they couldn’t play and then leave.
Sammy would quickly become frustrated if someone wasn’t playing the way he imagined the
game to go, and he would walk away and ask the caregiver if he could play his “alone animal
time” game instead. Sammy would let his brother and I play with him but when Sammy
attempted to explain the rules about his game, he would throw his hands up in the air and run
from one room to the other until he calmed down. Sammy was unable to understand why people
would ask questions about his game and how to play because he knew what he was thinking and
how the game would work and couldn’t process why others didn’t imagine things the way he
did.
When Sammy was about to turn seven, his parents pushed to have a large birthday party
and invite Sammy’s entire class from school. Sammy, his parents and I discussed this birthday
party plans with him three weeks in advance. However, Sammy worked better with a week-by-
week schedule because monthly schedules became overwhelming to him and would trigger

repetitive behaviors and outbursts. Sammy and I began “birthday party training” in preparation
for his party and made a calendar that clearly marked the day of the party.
Sammy enjoyed playing pretend games, if he was able to control most of the rules. I
allowed Sammy to pick the location and then I would create the scenarios that could be potential
situations at his birthday party. The training and preparation was meant to teach Sammy how to
play with other children at his birthday and how he would ask someone to play. The following
situation was setup in order to teach Sammy how to ask someone to play and initiate playing
with someone independently.
CL: Okay Sammy, I am going to go over here and play with these toy animals.
Sammy: (nods but stares at me from the door frame without moving)
CL: (five minutes passed so I play his country mix tape on my phone but remain sitting on the
floor) Sammy, what is the name of this animal again? I cannot remember.
Sammy: That’s an eagle Miss Christina; you know they live in Alaska! They are know for
having white feathers and being able to catch fish with their feet.
CL: Oh yes, that’s right. Thanks Sammy. Do you want to look up these birds in your animal
book and try to find them in your animal box?
Sammy: Yes. But I want to help hold the book while you read.
We continue looking through his animal book and animal toys and he has moved away
from the doorframe and is now sitting on the floor. I start to ask him about the children in his
class and what they enjoy playing. Sammy explains that most of the kids like animals and play
with a baby duck on Fridays.
CL: Okay, how do you think you should ask other kids if they want to play?

Sammy: Um, I don’t know. Maybe see if they are busy first? I know that when you are doing
homework or cooking dinner that you are busy so I don’t typically ask you for those times.
CL: Hmm, that’s a good idea. I think that is thoughtful too. What if they say they aren’t busy?
Sammy: If they say that then I will ask if they like birds. But the words… what if they get stuck?
When they get stuck I don’t know how I will get to play with them.
CL: When our words get stuck, what if we just sat down and tried to play with the other kids
anyways? You don’t necessarily have to use words to play with someone. You could try and just
sit next to them and start playing with them. When you feel like the words can come out, then try
and say hello and maybe one of you will come up with a fun game to play or you can talk about
birds and animals. People like to talk about things they like too so maybe you can ask them and
see if you have something in common.
Sammy: Since the party is about animals from Australia maybe they will want to hear about
Australia and we can pretend we are there. I like to imagine I am a zookeeper and that could be a
fun game to play.
CL: I think that’s a good plan. If you feel overwhelmed what would you do?
Sammy: I will try to breathe and sit for a minute but if it’s too much I will go to you or mom for
a minute.
This was difficult to teach Sammy and would often result in Sammy observing by a wall
or on a sidewalk and not initiating play. He could tell when someone was upset or happy in most
situations but when it came to joking around with Sammy, a glazed expression would fall over
his face. Any situation that involved play joking from his perspective would often led to a
meltdown. On Sammy’s birthday party, it took him two hours to get up the courage to go play
with his classmates. The party was at his house so he was comfortable with the setting but

remained close to me for a long period of time. I mentioned to Sammy several times about what I
thought would be fun for him to go play but he remained silent. I let Sammy be until he finally
found his animal and then kids began to come sit next to him and look at the pictures. Sammy
became less tense and then played in the yard with three other boys. Sammy did not
independently initiate play but he did engage in certain activities with the other children.
After three and half years, I had to leave the role as Sammy’s caregiver and complete
school. Leaving Sammy and his family was difficult for Sammy and myself. Sammy’s parents
wouldn’t let me prepare him for my departure. Sammy and I had two days to say goodbye. I
decided to tell him the day before I left because it was too difficult to think about him not
understanding why I needed to leave. I told Sammy at the grocery store when he was in a good
mood and then he just sat on the floor in the aisle. I sat with Sammy and he climbed in my lap as
usual and whispered, “snuggle, snuggle, snuggle”, over and over. I explained that I would still be
just around the corner and we could face time whenever he wanted. We sat in the aisle for thirty
minutes talking about fun things we’ve done and silly moments that makes him laugh. The
caregiver relationship ended the next day but also opened the door to the long lasting friendship
of Miss Christina and Sammy.
Lessons Learned from the Case Study
 The value and importance found within the caregiver and child relationship.
There is room for informalities within the client and therapist relationship in certain situations.
As the caregiver, it became apparent that dropping some principals in order to build a better
relationship with Sammy was what needed to be done in order to be an effective helper in his
development.

 The exploration of alternative therapeutic techniques when working with Sammy’s
Autism disorder.
Autism Spectrum Disorder does not affect everyone the same and if one technique works for
another individual with Autism this is not a guarantee that it will be effective for someone else
with ASD.
 Children with Autism Spectrum Disorder do not need to be “fixed” all the time
Sammy and I got along because I was not trying to change his personality but rather to accept
him for the way he is and work from there. Sammy was a loving and thoughtful child with a little
more obstacles than others. This never changed how I treated him but rather allowed me to
become more empathetic towards his struggles.
 Important characteristics of the caregiver or helper
As the caregiver, patience and understanding were necessary when working with Sammy.
Sammy had bad days and they could last hours sometimes, but I was able to understand that he
wasn’t always in control of how he was feeling. If Sammy did not comprehend changes in his
schedule, I became prepared to ask the same question ten times in a row and that is okay because
that is what helped him understand over time.

Findings
The purpose of my findings was to then compare and contrast my case study with
published academic data on Autism Spectrum Disorder and established techniques and
effectiveness on the benefits of play therapy with children. Since, Axline’s book, Play Therapy,
is recognized as one of first use of play therapy techniques with children, my findings went along
closely with her established play therapy techniques. As I was watching Sammy, I was not aware
that I was following Play Therapy techniques; I started noticing similarities in my techniques and
other therapist techniques when it came to using play as a natural medium when working with
children.
Axline repeatedly discussed the importance of the therapist and client relationship and
how rushing this therapeutic process in play therapy could be detrimental to the client’s progress
(Axline, 1969). As the caregiver, I found our techniques and processes similar when it came to
not rushing the child and avoid solution based treatment plans solely. The Sammy’s parents
worked seventy to eighty hour weeks. His parents would drop them off at school and then not
return home until eight-thirty or nine o’ clock at night. I saw Sammy and his brother for long
periods of time and put them to bed at night. When Sammy’s symptoms worsened, the parents
used negative reinforcements in hopes of getting Sammy’s attention. The situation did not get
better and any progress I made with Sammy the week prior was often forgotten when I came
back on Monday. Inconsistencies and sticking with calming mechanisms that were beneficial to
Sammy were rarely implemented on the weekends with their parents.
Atypical symptoms that are common in most individuals with ASD, include sleep
problems, sensory problems, repetitive behaviors, extreme stress when routine is changed and
emotional outbursts (Autism Speaks, 2016). If Sammy was extremely excited or stressed he

would jump in one place over and over. He would repeat this behavior up to an hour depending
on the situation. When Sammy was in this headspace I would let him jump because if you
attempted to correct the behavior it would trigger Sammy to cry hysterically. This behavior has
improved since my departure because Sammy is now on several medications to treat his
behavioral problems. Sammy was on the high functioning end of Autism and his pediatrician
told his parents and myself that medication should wait unless he is exhibiting self-harm
symptoms. Sammy never exhibited these symptoms.
Our “art therapy” and “social skills training” was used in both a directive and
nondirective therapeutic approach. Deciding if nondirective or directive therapeutic techniques
were based off of the severity of the situation in Sammy’s case. Nondirective and directive
therapy is a technique that was explained by Virginia M. Axline in her Play Therapy
observations when dealing with nonverbal children and children with social and behavioral
issues (Axline, 1969). If Sammy was verbal we would often try a nondirective approach to
promote his ability to make decisions independently. If Sammy was not communicating, I would
create an activity and use a directive approach by letting Sammy know what we were going to do
and what topic we would explore. Sammy using art as a therapeutic outlet was effective. In
relation to art therapy with Sammy and his picture of the butterfly, I mentioned earlier in the case
study that Sammy was nonverbal when the caregiver picked him up from school and no feelings
were being verbally expressed at the time. It took alternative methods to figure out what was
bothering Sammy that day. Art was a safe place for Sammy, art allowed him to speak freely and
talk to someone he felt comfortable around. Sammy was able to communicate seven times of ten
when he was having bad days after ten months of practicing “art therapy”.

Sammy never regressed to becoming completely unable to communicate verbally.
Sammy’s parents have seen an increase in communication skills and focusing abilities. Sammy
has grown out of the stage where he thinks that words are literally stuck in his throat preventing
him to speak. Through the span of three years, Sammy developed coping skills when he felt
emotional outbursts approaching. Sammy’s breathing exercises were soon initiated
independently after seven months of practicing this calming mechanism. Since my departure,
Sammy has added onto his list of coping strategies when he feels overwhelmed. Sammy carries a
piece of Velcro in his pocket to rub when he is feeling anxious and has stopped stretching out his
shirt collars when he is frustrating at school or if there is a change in the schedule. Sammy’s
mother has seen overall improvements, especially when it comes to listening to her.
Sammy still struggles with describing what is bothering him from time to time but his
teachers’ feedback says he seems less tense when an adult asks him if something is upsetting
him. The teachers said he participates in recess more now and walks up to other children play
more frequently. Sammy’s speech teacher has been able to decrease his speech classes from
three times a week to once a week or twice a week depending on his behavior.

Discussion
The discussion is a compilation of my own personal opinions and recommendations on my topic,
what are the benefits of play therapy in the development of social skills in children with Autism.
Writing about different therapies and theories and why I think these relate to my topic and that
there should be more research done on my research question.
The reasoning behind using alternative therapies like Play Therapy especially in children
is that children play through self-expression and observing a child’s behavior through this
avenue could give healthcare professional more accurate observations. These observations either
direct or nondirective could allow parents, teachers and Human Service professionals the ability
to see what area in the Autism triad that the child is struggling with more than others. This could
help others to identify if the child is high functioning in social skills but low functioning in
behavioral outbursts for example.
If a Human Service professional is working with a child or individual with Autism, I
found that observing nonverbal behaviors will give you a great deal of insight on how to
approach the child in the future and also it can serve as warning signs. As I said earlier, with
Sammy, when he would run in place, I began to realize he was not mentally present. Getting a
response from someone who is not mentally there can often lead to triggers or angry outbursts if
you keep pushing the question.
When seeing other therapists try to keep pressing the same question over and over it is a
good indicator that the child or individual is either not comprehending what you are asking or is
not ready to speak about it yet. The last thing you want to do is add more anxiety to a child with
Autism. If there is a safety issue then yes try to find a way to obtain the information but pushing
for a certain response or result will often lead to a frustrated child. This is important to

understand because if maintain patience and not rush the process, the individual will come to
you. I was fortunate to have time on my side in my case study with Sammy but it also was the
reason why our therapy techniques were successful and why our relationship was close and
comfortable.
Limitations to my study, this is an anecdotal case and the success and effectiveness relied
heavily on the amount of time that was available to me with the child. As the caregiver, a certain
degree of patience is required when dealing with Sammy’s atypical behavior and outbursts. As I
previously mentioned, the building trust and rapport with Sammy was a lengthy process but I
knew that trying to change Sammy to fit a “typical” six year old was not the right path for
Sammy to grow and progress. When dealing with individuals with a disability, it can be a
lengthy process and as the caregiver I was aware of this and prepared for it. Throughout our
journey, as the caregiver, I never tried to change Sammy’s personality but rather use his interests
and personality to our advantage.
Limitations to my study were also the inconsistencies with his parents and his
development. Sammy’s social skills began to develop because I was with him everyday working
with him and setting up various scenarios in a way he could understand. I was a dependable
person in Sammy’s day to day routine. This is important for parents to understand when having a
child with disabilities. The point is not to fix the child but rather work to teach certain coping
skills and social skills because this will be something Sammy lives with for life. Sammy doesn’t
need to be fixed, Sammy just needs a present caregiver to advocate for him and his progress.
A final recommendation when working with children or individuals with Autism is being
able to be compassionate and empathetic to their unique situations. I personally have had a
disability since I was twelve years old, so I understand obstacles and not understanding why

certain things are happening and why things may not be fair all the time. I was able to connect
with Sammy through that understanding and build upon that in our relationship. Sammy knew I
genuinely cared about him. When I left, Sammy told me that I was unique just as he was and that
he will miss me. All of us are unique and this is something important to tell your child if they
struggle with obstacles. You will not be able to change their circumstances as parents, teachers
or Human Service professionals but you will be able to make an impact in their life in one way
or another. I understand that not every therapeutic technique you try will work and that can be
frustrating for both parties but there are benefits in trying alternative therapies when working
with Autistic children. As I mentioned earlier, each ASD individual is different but if you
continue to find ways to figure out what interests them then you might find that one
breakthrough therapy technique that opens lines of communication again. These alternative
therapies are beneficial if you remain consistent.
Course Competencies
HS 4600 Working with Children and Youth, as the student in HS course Working with
Children and Youth, I gained knowledge through this course due to the client population
discussed, which is children and adolescents. The client population and therapeutic processes’
were discussed in detailed on how to deal with various cognitions and behavioral issues that are
common within children.
HS 3300 Human Socialization, as the student I learned the understanding and the
importance of social interaction as we develop through childhood. Teaching societal norms and
appropriate social skills amongst peers as children and adults was prevalent in learning more
especially in relation to children with disabilities.

HS 4500 Working with Families, as the student I learned how families or caregivers must
maintain a consistent and stable role in the development of a child. Children learn from their
parents for social behaviors and cues, and if their teaching is not consistent in relation to learning
social skills within their communities, it has the potential to lead to harmful behaviors or actions.

Appendices:
Appendix A: Pediatric Developmental Screening Flowchart

Appendix B: Example of the PEDS Questionnaire

Appendix C: The GARS Scale Example

Appendix D: A Venn diagram helps illustrate how autism frequently co-occurs with one or more
neurological and systemic health conditions.

Appendix E: Illustration completed by Sammy during an “Art Therapy” session

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