Sandplay - Autism 6n1h2l

The Arts in Psychotherapy 37 (2010) 56–64

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The Arts in Psychotherapy

Stimulating creative play in children with autism through sandplay Lucy Lu, M.A. a , Fiona Petersen, B.SW, DESS. a,∗ , Louise Lacroix, M.A., ATR a,b , Cécile Rousseau, M.D. a,c a

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-five 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, Heflin, 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 deficits 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, flexible, 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 beneficial to children with ASD.

∗ Corresponding author. E-mail addresses: [email protected] (C. Rousseau). 0197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2009.09.003

The gains for children with ASD in developing their ability to play is multifold as it is suggested that play provides a medium through which children develop cognitive and emotional skills, flexible thought, and experimentation with roles, as well as the opportunity to interact with others and to express themselves (Wolfberg, 1996). Structuring and enhancing play with children with ASD gives them a sense of mastery, as well as increasing their pleasure and their motivation to play, which is a justifiable aim in itself (Boucher, 1999; Wolfberg, 1996). There is a growing body of applied research (Jarrold, Boucher, & Smith, 1996; Jarrold, 2003; Libby, Powel, Messer, & Jordan, 1998; Sherrat & Donald, 2004; Sherratt, 1999, 2002; Wieder & Greenspan, 2003; Wolfberg & Schuler, 2006; Wolfberg, 1996) dedicated to understanding the obstacles that children with ASD face in initiating and producing spontaneous and imaginative play, devising means to and enhance it, and ultimately to help children with autism partake in their peers’ culture where play is of such central importance. Sandplay, the central tool of this program, as a creative medium is particularly adaptive to many different populations and settings. Inspired by Margaret Lowenfeld’s World Technique, Dora Kalff, a Jungian therapist, developed Sandplay in the 1940s as a non-verbal therapeutic modality to work with children (Kalff, 1980/2003). “Within the ‘free and protected’ space provided by the therapist, a child or adult creates a concrete manifestation of his or her inner imaginal world using sand, water, and miniatures objects. Thus, sandplay illuminates the client’s internal symbolic world and provides a place for its expression within a safe container, the sand tray” (Friedman & Mitchell, 2008, p. 1). Many adaptations have since been created (Mitchell & Friedman, 1994) including sandtray therapy that has been adapted to group

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situations and allows each participant the opportunity to create their own world while in the presence of others, with the possibility of sharing their experience with the group (De Domenico, 1999). De Domenico (1999) reports that sandtray therapy in a group context helped improve self-esteem, decrease isolation and withdrawal or extreme introversion, and increase curiosity and self-reflection. Sandplay has been used with children in individual therapy (Mitchell & Friedman, 1994; Van Dyk & Wiedis, 2001), and as a way to work therapeutically and preventively in school populations (De Domenico, 1999; Kestly, 2001; (as sandplay “without therapy”) Lan, 2008; Pabon, 2001), and with school-aged immigrant and refugee children to promote adaptation through creative expression (Lacroix et al., 2007; Rousseau, Lacroix, Singh, Gauthier, & Benoit, 2005). This type of creative group sandplay activity within a class in a school setting is a means to promote imaginative play and symbolic expression as well as facilitating communication. The focus is more educational and developmental than therapeutic; however, therapeutic effects may be apparent during the creative activity. Literature on sandplay populations with ASD is sparse (Tanguay, d’Aminico, Dolce, & Snow, 2004) and therefore needs further investigation to explore its potential as a tool to work with children with ASD. Children with ASD are often grouped in the same classroom despite displaying a wide range of social and cognitive abilities. Sandplay employed as a creative group sandplay activity presents the potential to stimulate play at multiple developmental levels from tactile exploration to early and more complex social play, from functional play to symbolic representation, and pretend play. Also sandplay does not completely depend on verbal expression, but does promote communication and shared meaning through the storylines developed in the play. In all these respects, sandplay has the potential to be adapted and incorporated into existing educational practices with children with ASD. As ASD populations demonstrate diverse learning needs, school policies in education advocate for personalized programming (Bryson et al., 2003), which will often incorporate a variety of treatments such as behavioral, developmental, and occasionally creative-based interventions within a structured educational framework (Hess et al., 2008). It has been noted that interventions are often modified and altered in the actual school setting (Stahmer, Collings, & Palinkas, 2005), suggesting that although an intervention has been proven effective in a controlled research setting, teachers need to find ways to incorporate the myriad intervention practices to the actual education settings when working with children with ASD. Action research provides an avenue to collaborate with educators, adapting the intervention as it is being studied (Stringer, 2007), in order to see how creative interventions can be integrated with and complement existing practices in the actual setting that address the core deficits of children with ASD. This preliminary study describes an action-research approach to investigate and ask the following questions: 1. How does sandplay adapted as a semi-structured creative intervention the developmental skills of children with ASD in the areas of communication, socialization, and symbolic elaboration? 2. How do children with ASD with different levels of impairment respond to the sandplay intervention? Description and rationale of intervention Each session took place during a 60 min class period and consisted of an opening ritual, a sandplay period, a storytelling

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exchange, and a closing ritual. The intervention was designed in such a way that it provided a structured routine, while also providing the framework for spontaneous and child-directed play and expression. Opening ritual Opening and closing rituals provide children with the consistency of a predictable beginning and clear ending that is reassuring and delimits the intervention from the regular school routine (Martin, 2001). The opening ritual was a brief 5–10 min activity that welcomed the children into the creative space using physical, verbal, and imaginary play as warm-ups to the sandplay activity. Ribbon sticks and egg shakers, encouraging gross and fine motor movement and rhythm, were used in brief activities involving mirroring, the naming of personal tastes and feelings, play acting, and collective storytelling. The opening rituals were designed to enhance affect and encourage sharing so that children could express and interject their ideas and create gestures that we could all imitate. Some examples included imagining being different animals, eating different favorite foods, reliving the Montreal Canadiens’ hockey win, or taking a camping trip together. Each ritual was modified to the developmental level and verbal capacity of each group of children. Sandplay The main activity of sandplay was adapted as creative group activity to address the play needs of children with ASD. Whereas Sandplay encourages a ive, containing role for the therapist (Lowenfeld, 1979), we practiced a semi-structured child-centered approach, employing techniques like narrating the child’s play, mirroring, and offering figurines to draw out the play, while remaining sensitive to the child’s reactions (see Knoblauch, 2001). This type of relational approach to play is based on principles of the Floortime model (Greenspan & Wieder, 2006), that encourage observing, following the child’s lead, opening and closing circles of communication, so that children can elaborate on their self-initiated gestures in order to expand on their ideas and imagination. The aim of using a relational approach in this intervention was to help the development of imaginative play. Although the sandplay intervention was adapted for the school context, the main identifiers of sandplay were utilized. A sandtray, according to Kalff’s dimensions (1980/2003), was provided for each participant as well as bins grouping different figurines and objects that the children would share. In sandplay, one can choose from a vast array of miniature human and animal figures (both realistic and fantastic), trees, transportation, housing, and food, as well as miscellaneous objects such as marbles and feathers that provide color, textures and material for original constructions, to create scenes in a sand tray (Kalff, 1980/2003). The inside of the sand tray is painted blue, so it can easily represent the sky or a body of water. Kalff (1980/2003) insists on trays of a very specific size, corresponding to the child’s central field of vision and facilitating safe immersion in play. The frame is also purported to have a limitsetting function (Carey, 1990) and acts as a regulating, protective factor (Kalff, 1980/2003). The sand provides a soothing medium that stimulates the sense of touch, smell, and sight and is often associated with playing in the park or on beaches (Lacroix, 2002; Steinhardt, 1998). Small quantities of water were offered as an additional tactile dimension to the sand quality and played a role in attracting and sustaining children’s attention. The different tactile qualities of the sand and the diversity of figurines and objects stimulated imaginative play, which eventually moved to the process to storytelling.

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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 specific 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 modifications 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 6–7 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 1–3, while during the intervention the ratio was 2–3. Children participating in the program ranged from the ages of 7–12 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 reflected 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 final 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 children’s symbolic capacity

Table 1 Categories of creative expression. Creative expression

Sub-categories

(1) Pre-symbolic expression

(1.1) Tactile or sensorial exploration (1.2) Functional play

3 4

3:0 4:0

8–9 8–12

8.7 9.8

(2) Symbolic expression

(2.1) Ritualistic play (2.2) Beginnings of story-telling (2.3) Symbolic themes organized into story form

6 7 5

5:1 7:0 4:1

7–10 7–12 10–12

9.3 10 11.2

7–12

9.9

Total number of children (N)

Number of children (n)

25

Gender ratio of boys:girls

Boys n = 23; girls n = 2

Age range

Mean age (M)

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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 , 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 findings A content analysis (Stringer, 2007) was made of the data collected from the observation grids, the images of the sandtrays, and the teacher’s 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 complexification 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 findings 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 children’s behaviour. It was possible to note changes in the complexification 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 flexibility as new elements borrowed from other children’s sandtrays

Fig. 1. Session 1—Sheldon’s line of glass beads.

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were incorporated into their play. Most children demonstrated some awareness of their peers through their practice of mirroring or imitating their choice of figurines, their use of water, the way they structured or placed figurines in their sandtrays, and through their attentive listening to their peers’ stories. Their play was enhanced as they built on each other’s ideas through this social interaction. The children tended to progress, as is particular to sandplay, in a spiral rather than a linear fashion (Weinrib, 1983/2004). In this way, the same sandtrays can be reproduced from week to week with only minor changes and then move to a new level of development as the sandplayer integrates new experiences in their creative process. Further descriptions of the findings highlight the specific details of the two sub-groupings of pre-symbolic and symbolic expression, with vignettes to illustrate the five sub-categories. Pre-symbolic expression Tactile and sensorial exploration: non-verbal (naming some needs) The pre-symbolic play of children of this first category (n = 3) was characterized by engaging on a sensory level with the sand and a few objects with tactile qualities. There were some indications of functional play, such as moving a bus back and forth. Occasionally, one child would draw simple faces in the sand; however, for all three children there was no sustained creation in the sandtrays, nor any symbolic interactions with the figurines. Water played an important function in attracting and sustaining interest and concentration in the activity. Communication, which was predominantly non-verbal, was sustained through the medium of sandplay by exploring the properties of the dry and wet sand and of certain tactile objects by squishing, rolling, and hiding them in the sand with the child, or by playing directly with him by hiding and catching his hands in and under the sand. The autonomy of each child differed, ranging from an ability to sustain attention as the workshops progressed, to requiring one-on-one interaction with the therapist/teacher to stimulate t attention. Children were rarely able to engage with other peers for longer than a few interactions. Engaging these children in the opening rituals proved more challenging but was facilitated through clear directions ed by pictograms and g made available by the teachers and special educators. The closing ritual, on the other hand, because of its unchanging nature and group dynamic, proved largely popular and two of the boys began actively participating in the activity as they became more engaged and accustomed to the routine. Vignette: Sheldon. Sheldon, a 9-year-old boy who was present for all 10 sessions, had a tentative initial with sandplay. He played with some sticky, stretchy worms and was given a small quantity of water to rinse them with. On this first day he merely poured the water into the sand. His attention was very limited although he lined up some marbles a teacher offered him (Fig. 1). Sheldon was very restless during the first four sessions leaving his seat to look for more water or for something else to do, making loud lamenting sounds and dropping toys on the ground. Although Sheldon’s verbal communication was very limited he did ask for water to play with each week. Water became a means of engaging with the sand, by changing its properties; as well as engaging him with people as he expressed his need for it. Apart from occasionally functionally playing with a school bus, the majority of Sheldon’s play was sensorial. The therapist elaborated upon his play with marbles and bright, sticky creatures, at first by moving the worms along his arms, which he enjoyed. When his teacher began playing a hide-and-seek game with him by hiding her own hands in the sand and touching Sheldon’s hands beneath it, his attention was fully aroused and an intense non-verbal interaction

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Fig. 3. Session 2—Ryan’s functional play with a bus.

Fig. 2. Session 5—Sheldon engaged in sensory play.

was established. Each subsequent session began with him pouring water in the sandtray and mixing it through burying his hands in the sand and inviting, through eye , for them to be found. He was then able to play on his own with the worms and marbles for an extended period of time (Fig. 2). As he began to experience some shared attention and became more regulated through the structure provided, his affect became more positive and his attention increased to the duration of the 45-min workshop. Sheldon, who spoke rarely, began saying “bye-bye” to his sandtray each time he left, perhaps indicating an emotional investment in the activity of sandplay. Pre-symbolic/functional play Each child of this sub-category (n = 4) was able to move from pre-symbolic functional play to the beginnings of symbolic play. In most cases, the children were limited in their verbal expression. They communicated with a few short phrases, some responded with echolalia, and some were able to use appropriate greetings such as “hello, how are you?”. Their participation was much more expressive during the rituals than in the less practiced context of talking about their play. Occasionally, indications of shared meaning in communication within the play were present. All the children in this group benefited from social interaction, mostly with teachers and therapists, but also from imitating other children’s work, such as adding water to the sand. The children’s language became more articulate during their play as they began to master what they were doing. Their initial play was characterized by a sensory exploration of the figurines and the qualities of the sand and some functional play. For several weeks the children would resist attempts to extend and expand on their play, closing circles of communication very quickly. Through close observation of the play and placing a prompt at the right moment, eventually the point of entry would be found and the child’s play would move to a deeper level of complexity. No sustained storyline was achieved for this group but rather pieces of stories were created: “the animal drinks from the well”; “The Ford pick-up lives at this house”; “the bus was attacked by a crocodile.” All the boys, through much trial and error in extending and expanding their play, reached, by the end of the 10 sessions, a level of representational play conducive to the elaboration of a more complex symbolic play and storyline. Vignette: Ryan. Ryan is a timid, gentle 9-year-old boy, who had a strong tendency to respond with echolalia. He was present for all 10 sessions. He agreeably took any figurine offered to him but soon put it down and continued functionally playing with a school bus or fire truck, which he moved timidly around the sandtray (Fig. 3).

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. Ryan’s 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 figurine 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 figures from the figurine bin and identified 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 Ryan’s spontaneous symbolic play, as well as a significant 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, fire trucks and firemen 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.

Fig. 4. Session 9—Ryan’s emotional investment to the play.

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Fig. 5. Session 2—Mario’s rigid and ritualistic ‘sports’ game.

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 difficult 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 figurines with a repeated set of actions or scripts in each session that had little variation or flexibility. Disorganization was apparent through chaotic placement or randomly filling the tray full of figurines. In 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 difficult for the teachers and facilitators to find 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 , 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 figurines 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 first session Mario’s play in the sand tray was characterized by rigid placement of figurines between two goal posts playing “sports.” Throughout the play he seemed to perseverate by remaining fixed 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 finishing 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 flags in the tray, and often there were so many figurines that more and more would be placed outside of the sandtray. Mario

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made attempts towards symbolic interaction by placing the figurines facing each other; however, his rigid play did not provide him with the fulfillment 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 George’s play by having the figurines “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 figurines 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 benefited 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 other’s sandtrays and told stories together. Many of them would incorporate figurines or stories that would be inspired from the exercises or from observing other children’s story images. The symbolic themes in the sandplay of this group ranged in complexity and included age-appropriate themes of aggression/fighting/death/fear; accidents and rescue stories; sharing and nurturance; repairing when characters were hurt; and activities from their daily lives—school, eating, sports, and birthdays. In this group there was a range of different intellectual abilities, which reflected 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 (conflict/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 inflection or repetition. In his first 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 traffic 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 influenced by the imaginary play theme of animals in our

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Fig. 6. Session 1—Emile’s school bus in the neighborhood.

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 fly buzzing (making the sound)”. Although he repeated this springtime image for another two sessions, it appeared that Emile became more influenced 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 confidence 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, conflict 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 difficulties at home, frustrations with physical limitations, or personal tension with classmates.

Fig. 7. Session 5—Emile’s springtime and people.

Fig. 8. Session 3—Isaac’s detective story.

Children sought interaction with the therapists and teachers, and enjoyed communicating their stories to the class. Children of the 4th and 5th category were very appreciative audiences for their peers: they laughed, asked questions, expressed iration as well as comion and sadness. In a very few cases, irritation or mockery was expressed as well. Children of this group participated actively in rituals often offering personal anecdotes, creating collective stories, and participating in pretend play such as hiking through a mountain and camping in a cave. Themes from the opening ritual were often present in the sandplay. In summary, children of this sub-group were able to express complex emotional content and link several ideas into a relatively coherent storyline. The sandplay offered them a medium to elaborate on this capacity, in some cases write stories from their sandplay (often for the first time), as well as providing them a medium to interact with peers and teachers. Vignette: Isaac and Jean-Claude. Isaac is a thoughtful, articulate 11year-old boy who often verbalized his actions of play with private speech. Like many of his classmates, he initially enacted a game of soccer. By the third session, Isaac stopped himself midway setting up another game saying, “no, I want to tell a story,” choosing to let go of the familiar sports script. He then created a dramatic story involving kidnapping, detective work, and supernatural interventions, and he connected with the emotions of his characters relating, “He did not find his grandmother and began to cry” (Fig. 8). Role-playing and pretend imaginings involving object substitution and symbolic thinking were demonstrated in subsequent sandplays created with his fellow classmate Jean-Claude, a 12-yearold boy with a keen sense of humor who often initiated invitations to play with Isaac. Isaac solved the problem of having Jean-Claude idly wait while he narrated the story, by giving his classmate the role of cameraman. Isaac turned a mirror upside down and the hole in the handle became the lens through which either child could film the other’s story. Jean-Claude, although feeling a bit self-conscious at first, “filmed” Isaac’s story and, in this manner, his symbolic play was enhanced (Fig. 9). Isaac, through this game, began to express a meta-cognition of play in the sense that he was able to step out of his play, observe his play and attempt to share his symbolic play with his peer. The boys complemented each other as Isaac contributed elaborate storylines that tended to get bogged down in detail whereas Jean-Claude added drama and realism through such devices as robberies and asg more logical outcomes to the stories, such as the police arriving to assist the victims. Some of the themes of the stories sparked interesting discussion about their knowledge

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Fig. 9. Session 8—Isaac and Jean-Claude’s shared story and ‘film’.

of religious practices or preferred movies. The medium of sandplay allowed these higher-functioning children with autism a space to interact and focus t attention on a creative activity while ing 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 for play and creative expression. The sand and the diverse array of figurines ed sensory and symbolic play; the individual sandtrays delimited a protected space; while social interaction and expressive communication was encouraged through the sharing of figurines, 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 ing 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 ed 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 flexibility 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 ing emotional regulation as well as two-way engagement by enhancing and expanding on sen-

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sory exploration and functional play through making an emotional connection to the child’s experience. According to developmental theories of play (Greenspan & Wieder, 2006; Wolfberg, 1996), a child’s ability to engage in higher levels of spontaneous communication, socialization, and symbolic elaboration is based on shared attention and sustaining two-way pre-symbolic communication. The sandplay intervention demonstrated that it could be a medium used to develop the core deficits of children with autism, while at the same time ing children operating at higher functional emotional levels within the same classroom setting. Children expressing at a symbolic level of play and story development appeared to benefit from the sandplay intervention by having the visual figurines and objects to sustain the development of their emotional thinking and linking abstract ideas into coherent storylines. As children became familiar with the medium and gained confidence in creating sandplay images, they became more at ease with interacting with each other, listening to each other, and being able to narrate their stories for their classmates and teachers. The children that had the least progression in this category were children showing rigid, ritualistic, and perseverating tendencies in their play, which made it challenging for therapists to intervene and find a point of entry into their play. However, just as the other children in this category who functioned at higher levels of symbolic expression benefited from the shared attention of the sandplay and social interaction from peers and adults during the intervention, it seems promising that this group of children could also benefit from more sandplay sessions to develop theses skills of play. More research is necessary to investigate how sandplay could provide the medium and social interaction to interrupt perseverative play; however, it seems to current theories (Sherratt, 2002; Wolfberg & Schuler, 2006), that symbolic play can be enhanced by watching or interacting with peer models. Sandplay was adapted as a group creative play program using a relational approach to play (Greenspan & Wieder, 2006) in a semi-structured format, in order to provide the structure that is the cornerstone of programs for children with ASD (National Research Council, 2001), while also providing an open-ended, creative space to spontaneous communication, socialization, and symbolic play. Sandplay offered a unique combination of sensory stimuli (sand, water, colorful, and textured objects), the raw material for story making (figurines, building materials), containment and a free creative space, as well as social and stimulation. In this sense the structure and materials ed the relational approach elaborated in Greenspan’s (2006) Floortime method, but structured and ed the ability to work with a small group of children with varying degrees of developmental abilities. Sandplay adds a relational triangular component, in the sense that the interaction is through the sandplay, whereas Floortime is designed as an interpersonal and open-ended dynamic. The use of an action-research methodology provided the framework that allowed for teachers’ input into the program and adjustment by the therapists to the various developmental needs of the children. Teachers were invaluable contributors as their knowledge of the children helped to identify types of play that they enjoyed, such as Sheldon’s hide-and-seek play, and provided insight into how the children’s play reflected their interests or personal experiences. The teachers’ introduction of a story structure around the play provided positive , for certain students, for organizing the narration of their sandplay. Thus, teachers’ goal of stimulating creative writing harmonized well with the overall objective of stimulating symbolic elaboration and communication. However, it appeared also that for some children this extra structure created pressure to conform to a certain level of storytelling they had not yet attained. The use of a minute timer provided by another teacher to delimit the storytelling appeared to meet the children’s need

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for structure without too much constraint or expectation. Further investigation is needed to evaluate the impact of restraining the number of figurines available for certain children with ASD, specifically those with the tendency to perseverate. In some cases, like the practice of limiting the amount of water provided, this would appear to be recommended, in other instances providing regulation through interaction with the children through the play (providing traffic lights, police, or referee figures) would seem sufficient, and in the case of Mario, he appeared to interrupt his own perseverating play by imitating another child’s play that he found more stimulating. Further research is needed to replicate this work and to confirm the benefits of providing, through such a program, a more creative, less structured, and non-goal oriented space to meet existing educational goals for children with ASD. Once the benefits of sandplay to creative symbolic thinking in children with ASD has been investigated, further research is needed to evaluate to what extent the program can be transferred to teachers to implement and how much training, external , and supervision is necessary to successfully disseminate the program in schools. Finally further study is encouraged to see how sandplay adapted as a creative group activity within the classroom can be applied also to the needs of other children who may experience other social or emotional difficulties. In conclusion, sandplay adapted to children with ASD appears to provide the potential of enough structure around a free and unfocused creative space to the developmental skills of communication, socialization, and symbolic elaboration. Children respond and interact with the medium at their individual developmental level, which makes it an ideal medium to be used in a school setting for classrooms with various developmental needs. Acknowledgements The research findings from this school intervention were based on an action research investigated by school psychologist Déogratias Bagilishya, professor and art therapist Louise Lacroix, from Concordia University, along with the Youth Mental Health Team (CSSS), and was funded by the Quebec Ministry of Education, Sports and Leisure. We would also like to thank the students, parents, teachers, special needs educators and staff at École SimoneDesjardins for their participation and in this research. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.aip.2009.09.003. References Boucher, J. (1999). Editorial: Interventions with children with autism - methods based on play. Child Language Teaching & Therapy, 15(1), 1–5. Brock, S. E., Jimerson, S. R., & Hansen, R. L. (2006). Identifying, assessing and treating autism at school. New York: Springer. Bryson, S. E., Rogers, S. J., & Fombonne, E. (2003). Autism spectrum disorders: Early detection, intervention, education, and psychopharmacological management. Canadian Journal of Psychiatry, 48(8), 506–516. Carey, L. J. (1990). Sandplay therapy with a troubled child. The Arts in Psychotherapy, 17, 197–209. De Domenico, G. S. (1999). Group sandtray-worldplay: New dimension in sandplay therapy. In D. S. Sweeney, & L. E. Homeyer (Eds.), Group play therapy: How it works, whom it’s best for (pp. 215–233). San Francisco: Jossey-Bass Publishers. Friedman, H. S., & Mitchell, R. R. (Eds.). (2008). Supervision of sandplay therapy. London and New York: Routledge. Greenspan, S. L., & Wieder, S. (2006). Engaging autism: Using the floortime approach to help children relate, communicate, and think. Cambridge, MA: Da Capo Press.

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