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The Arts in Psychotherapy 37 (2010) 56–64

Contents lists available at ScienceDirect

The Arts in Psychotherapy

timulating creative play in children with autism through sandplay

ucy Lu, M.A.a, Fiona Petersen, B.SW, DESS.a,∗, Louise Lacroix, M.A., ATRa,b, Cécile Rousseau, M.D.a,c

Youth Mental Health, CSSS de la Montagne (CLSC Parc Extension), 7085 Hutchison Room 204.2, Montreal, QC, Canada H3N 1Y9Department of Creative Arts Therapies, Concordia University, 1455 de Maisonneuve Blvd. West, SVA 264, Montreal, QC, Canada H3G 1M8Division of Social and Cultural Psychiatry, McGill University, Canada

r t i c l e i n f o

eywords:andplaylayutism spectrum disorders

a b s t r a c t

A school-based action-research intervention with children with autism spectrum disorders investigatedwhether sandplay could be used as a medium to stimulate creative and symbolic play. Twenty-five ele-mentary school children in four separate special education classes within the regular school systemparticipated in sandplay workshops once a week for 10 sessions. The intervention aimed to stimulate

chool-based interventionsction research 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 increasedverbal expression, engaged and sustained social interaction, and increased symbolic, spontaneous, andnovel play. The study suggests that creativity-based interventions provide a complementary approach to

ed int

behavior/social skills-basspectrum disorders.

ntroduction

The current practice of education of children with autism andervasive development disorders (PDD), or more generally autismpectrum disorders (ASD), in Canada and more widely in Northmerica, has largely focused on integrating children into the main-tream education system, whether in special education classes in aegular school setting or individual children integrated into regularlass settings (Brock, Jimerson, & Hansen, 2006; Bryson, Rogers, &ombonne, 2003; Hess, Heflin, Morrier, & Michelle, 2008). School-ased education approaches for children with ASD demonstratepropensity towards highly structured behavior-based interven-

ions, which have proven effective in addressing the core deficitsn communication, social interaction, and restricted repertoire ofehaviors, activities and interests (Brock et al., 2006; Nationalesearch Council, 2001). Although structured learning is essential

or this population to learn functional skills, proponents of develop-ental approaches contend that behavioral approaches are limited

n encouraging natural interpersonal interactions and spontaneousymbolic play (Greenspan & Wieder, 2006, 2007). As spontaneous,

exible, imaginative, and social qualities of play are typically under-eveloped with children with ASD (Wing & Gould, 1979; Wolfberg,996), interventions that can promote this quality of play could beeneficial to children with ASD.

∗ Corresponding author.E-mail addresses: lucyluAT@gmail.com (L. Lu), fiona.p@sympatico.ca

F. Petersen), louise-lacroix@videotron.ca (L. Lacroix), cecile.rousseau@mcgill.caC. Rousseau).

197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.aip.2009.09.003

ervention models prevalent in schools working with children with autism

© 2009 Elsevier Inc. All rights reserved.

The gains for children with ASD in developing their ability toplay is multifold as it is suggested that play provides a mediumthrough which children develop cognitive and emotional skills,flexible thought, and experimentation with roles, as well as theopportunity to interact with others and to express themselves(Wolfberg, 1996). Structuring and enhancing play with childrenwith ASD gives them a sense of mastery, as well as increasingtheir pleasure and their motivation to play, which is a justifiableaim in itself (Boucher, 1999; Wolfberg, 1996). There is a growingbody 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 theobstacles that children with ASD face in initiating and producingspontaneous and imaginative play, devising means to support andenhance it, and ultimately to help children with autism partake intheir peers’ culture where play is of such central importance.

Sandplay, the central tool of this program, as a creative mediumis particularly adaptive to many different populations and settings.Inspired by Margaret Lowenfeld’s World Technique, Dora Kalff, aJungian therapist, developed Sandplay in the 1940s as a non-verbaltherapeutic 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 innerimaginal world using sand, water, and miniatures objects. Thus,

sandplay illuminates the client’s internal symbolic world and pro-vides a place for its expression within a safe container, the sandtray” (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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ituations and allows each participant the opportunity to createheir own world while in the presence of others, with the possi-ility of sharing their experience with the group (De Domenico,999). De Domenico (1999) reports that sandtray therapy in aroup context helped improve self-esteem, decrease isolation andithdrawal or extreme introversion, and increase curiosity and

elf-reflection. Sandplay has been used with children in indi-idual therapy (Mitchell & Friedman, 1994; Van Dyk & Wiedis,001), and as a way to work therapeutically and preventively

n school populations (De Domenico, 1999; Kestly, 2001; (asandplay “without therapy”) Lan, 2008; Pabon, 2001), and withchool-aged immigrant and refugee children to promote adapta-ion through creative expression (Lacroix et al., 2007; Rousseau,acroix, Singh, Gauthier, & Benoit, 2005). This type of creativeroup sandplay activity within a class in a school setting is aeans to promote imaginative play and symbolic expression asell as facilitating communication. The focus is more educa-

ional and developmental than therapeutic; however, therapeuticffects may be apparent during the creative activity. Literaturen sandplay populations with ASD is sparse (Tanguay, d’Aminico,olce, & Snow, 2004) and therefore needs further investigation

o explore its potential as a tool to work with children withSD.

Children with ASD are often grouped in the same classroomespite displaying a wide range of social and cognitive abilities.andplay employed as a creative group sandplay activity presentshe potential to stimulate play at multiple developmental lev-ls from tactile exploration to early and more complex sociallay, from functional play to symbolic representation, and pre-end play. Also sandplay does not completely depend on verbalxpression, but does promote communication and shared mean-ng through the storylines developed in the play. In all theseespects, sandplay has the potential to be adapted and incor-orated into existing educational practices with children withSD.

As ASD populations demonstrate diverse learning needs, schoololicies in education advocate for personalized programmingBryson et al., 2003), which will often incorporate a varietyf treatments such as behavioral, developmental, and occasion-lly creative-based interventions within a structured educationalramework (Hess et al., 2008). It has been noted that interven-ions are often modified and altered in the actual school settingStahmer, Collings, & Palinkas, 2005), suggesting that although anntervention has been proven effective in a controlled researchetting, teachers need to find ways to incorporate the myriad inter-ention practices to the actual education settings when workingith children with ASD. Action research provides an avenue to col-

aborate with educators, adapting the intervention as it is beingtudied (Stringer, 2007), in order to see how creative interventionsan be integrated with and complement existing practices in thectual setting that address the core deficits of children with ASD.his preliminary study describes an action-research approach tonvestigate and ask the following questions:

. How does sandplay adapted as a semi-structured creative inter-vention support the developmental skills of children with ASDin the areas of communication, socialization, and symbolic elab-oration?

. How do children with ASD with different levels of impairmentrespond to the sandplay intervention?

escription and rationale of intervention

Each session took place during a 60 min class period andonsisted of an opening ritual, a sandplay period, a storytelling

herapy 37 (2010) 56–64 57

exchange, and a closing ritual. The intervention was designed insuch a way that it provided a structured routine, while also pro-viding the framework for spontaneous and child-directed play andexpression.

Opening ritual

Opening and closing rituals provide children with the consis-tency of a predictable beginning and clear ending that is reassuringand delimits the intervention from the regular school routine(Martin, 2001). The opening ritual was a brief 5–10 min activitythat 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 motormovement and rhythm, were used in brief activities involvingmirroring, the naming of personal tastes and feelings, play act-ing, and collective storytelling. The opening rituals were designedto enhance affect and encourage sharing so that children couldexpress and interject their ideas and create gestures that we couldall imitate. Some examples included imagining being differentanimals, eating different favorite foods, reliving the Montreal Cana-diens’ hockey win, or taking a camping trip together. Each ritualwas modified to the developmental level and verbal capacity ofeach group of children.

Sandplay

The main activity of sandplay was adapted as creative groupactivity to address the play needs of children with ASD. WhereasSandplay encourages a passive, containing role for the therapist(Lowenfeld, 1979), we practiced a semi-structured child-centeredapproach, employing techniques like narrating the child’s play,mirroring, and offering figurines to draw out the play, whileremaining sensitive to the child’s reactions (see Knoblauch, 2001).This type of relational approach to play is based on principles ofthe Floortime model (Greenspan & Wieder, 2006), that encour-age observing, following the child’s lead, opening and closingcircles of communication, so that children can elaborate on theirself-initiated gestures in order to expand on their ideas andimagination. The aim of using a relational approach in this inter-vention was to help support the development of imaginativeplay.

Although the sandplay intervention was adapted for the schoolcontext, the main identifiers of sandplay were utilized. A sandtray,according to Kalff’s dimensions (1980/2003), was provided for eachparticipant as well as bins grouping different figurines and objectsthat the children would share. In sandplay, one can choose froma vast array of miniature human and animal figures (both realisticand fantastic), trees, transportation, housing, and food, as well asmiscellaneous objects such as marbles and feathers that providecolor, textures and material for original constructions, to createscenes in a sand tray (Kalff, 1980/2003). The inside of the sandtray is painted blue, so it can easily represent the sky or a bodyof water. Kalff (1980/2003) insists on trays of a very specific size,corresponding to the child’s central field of vision and facilitatingsafe immersion in play. The frame is also purported to have a limit-setting function (Carey, 1990) and acts as a regulating, protectivefactor (Kalff, 1980/2003). The sand provides a soothing mediumthat stimulates the sense of touch, smell, and sight and is oftenassociated with playing in the park or on beaches (Lacroix, 2002;Steinhardt, 1998). Small quantities of water were offered as an addi-

tional tactile dimension to the sand quality and played a role inattracting and sustaining children’s attention. The different tactilequalities of the sand and the diversity of figurines and objects stim-ulated imaginative play, which eventually moved to the process tostorytelling.

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torytelling

A storytelling period followed the sandplay activity for the moreerbally expressive groups of children. For the younger and lesserbal groups, limited verbal exchanges would be one-on-one withhe teachers or therapists, or occasionally children were invitedy the therapists to walk around and view the sandplay imagesf their classmates, and to make one- or two-word descriptionsf their favorite objects. The more verbally expressive groups ofhildren were able to sustain enough attention to view and listeno each of their classmates, as they either enacted or told their moreeveloped stories. In some instances, a few of the children chose toork together to make collective sandtrays and stories.

The participatory nature of action-research encouraged the col-aboration of teachers to modify the intervention to meet thepecific developmental and academic needs of the children. Forxample one teacher structured the storytelling by asking the chil-ren to name the time, place, plot, and ending to their stories, whilenother teacher contained the activity by holding up a 2-min timer.he children appreciated the structure as it formalized the activ-ty, providing them the undivided attention of their viewers. Manyhildren who appeared unfocused during their play made up storiesn the spot for their teachers and peers to appreciate. Regardlessf the changes or modifications made to this storytelling section,ach class ended with the same closing ritual.

he closing ritual

The closing ritual remained constant and consisted of handlapping that mimicked the beginning, climax, and ending of aainstorm. Excess energy from the activity allowed an emotionalelease through the dynamic physical movements at the climax ofhe storm, while the slow mimicking of the patter of rain providedcalming group experience that permitted transition back to the

egular school program. The children often requested to direct theamiliar activity themselves, which led to unforeseen offshoots ofhe ritual, such as changing the rhythm, or adding different ges-ures or sounds, or adding their own personal touches such as theun coming out in the end. The closing ritual acted as a predictableontainer to the creative space and, when it was child-directed,t promoted self-esteem, group awareness, and the creative andmotional investment that enhanced its appeal for the children.

ethod

ction research

Following on previous research using sandplay adapted to achool setting (Lacroix et al., 2007), in this research two art ther-pists implemented a creative intervention using sandplay and

nteractive symbolic games. Action research is based on the premisehat research be conducted on real problems or issues faced byractitioners in order to develop localized solutions (Stringer,007). In this case school teachers and psychologists working withhildren with ASD in an integrated school setting expressed the

able 1ategories of creative expression.

Creative expression Sub-categories Nu

(1) Pre-symbolic expression (1.1) Tactile or sensorial exploration 3(1.2) Functional play 4

(2) Symbolic expression (2.1) Ritualistic play 6(2.2) Beginnings of story-telling 7(2.3) Symbolic themes organized into story form 5

Total number of children (N) 25

herapy 37 (2010) 56–64

need to implement a more diverse range of therapeutic and edu-cational practices that would meet the needs of children withASD. This research objective aimed to investigate whether cre-ative interventions, such as the use of sandplay, could be used as asemi-structured pedagogical tool that teachers could appropriatein order to promote communication, socialization, and the capacityto symbolize.

Population and setting

The children were a part of four special needs classrooms inan elementary school setting in Montreal, Canada, designated forchildren who met standardized criteria for autism and PDD. Eachclassroom had 6–7 children, with one teacher, one special needseducator, and occasionally a special education intern. The normalratio of adults to children in the class was approximately 1–3, whileduring the intervention the ratio was 2–3.

Children participating in the program ranged from the ages of7–12 years old, with an average age of M = 9.9 (N = 25), of which23 were boys and 2 were girls (Table 1). Children were assignedto their class according to age and developmental level. However,even within these assignments, there was a large range of develop-mental expression within each class. In addition to the diagnosisof autism or PDD, some children also demonstrated delays inmotor coordination and impaired hearing affecting elocution. ThisFrench-speaking school was representative of an ethnically and lin-guistically diverse school setting in Montreal and, despite the smallnumbers in these classes; the composition of the special needsclasses reflected this diversity.

All parents consented to permit their children to participate inthe intervention and research. Most of the children participatedin the entire length of the 10-week program, with some absencesamong six students for one to four sessions due to occasional sick-ness. On average, there was a 95% attendance of students to all ofthe 10 sessions.

Data collection

Qualitative data were collected after each session following anobservation grid based on symbolic developmental levels of play byGreenspan (Greenspan & Wieder, 2006) and grids of former sand-play projects by the team (Lacroix et al., 2007) (see Appendix A).Observations of each child were noted for receptive and expressivecommunication, social interaction, and symbolic expression duringall phases of the intervention. Children left the images intact aftereach session and the therapists cleared the tray before the nextgroup. Photographs of each final image of the sand tray were takenalong with particular reconstructions of images that were perti-nent to the storytelling. As each child differed in their capacity toexpress and communicate verbally the stories they created, obser-

vations were noted of their affect during play, level of engagementwith the materials, social interactions, and any verbalizations orstories they made about their sandplay.

Teachers completed a questionnaire about their expectations ofthe program and observations of the children’s symbolic capacity

mber of children (n) Gender ratio of boys:girls Age range Mean age (M)

3:0 8–9 8.74:0 8–12 9.8

5:1 7–10 9.37:0 7–12 104:1 10–12 11.2

Boys n = 23; girls n = 2 7–12 9.9

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efore the 10-week intervention. The two art therapists and thesychologist met with the teachers at the beginning, middle, andnd of the program to gain feedback, share observations, and toiscuss the program. At the end of the program, a focus group waseld with the teachers by another member of the team.

nalysis of findings

A content analysis (Stringer, 2007) was made of the data col-ected from the observation grids, the images of the sandtrays, andhe teacher’s observations. An initial global analysis of the programas noted for the level of engagement of the children in the activ-

ty, the capacity to engage symbolically and the complexificationf stories over time. In the second level of analysis, children wereategorized according to similar descriptive developmental charac-eristics along the three dimensions of our study: communication,ocialization, and symbolic elaboration (see Table 1). The two sub-roups that emerged from analyzing the production of the imagesnd the story progression were children that were characterizedy (1) pre-symbolic expression and (2) symbolic expression. There-symbolic group was further categorized into two sub-groupsf tactile or sensorial exploration and functional play. The sym-olic group revealed three sub-categories of rigid and ritualisticlay, beginnings of storytelling, and symbolic themes organized

nto story form. From each group, an analysis was made of theommon developmental capacities and symbolic themes and ten-encies demonstrated in the sand tray.

eneral findings

The sandplay workshops appealed to the children, who mani-ested their appreciation by participating with enthusiasm, joy andride in both the rituals and the sandplay activity. Their teach-rs reported that they anticipated and talked about the workshopseveral days in advance.

Within the 10-week period of the workshops no negative oregressive reactions, such as poor concentration or increased agi-ation in class following a session, were observed or reported byhe teachers concerning the children’s behaviour. It was possible toote changes in the complexification of symbolic use in the sand-rays and the stories told, as well as improvement in the generalttention and participation of most children. For instance, several

ighly avoidant children engaged in social play, others moved from

unctional play to incorporating some symbolic representationallay, while others elaborated on their symbolic and imaginary play.he rigid play of certain children began to demonstrate more flex-bility as new elements borrowed from other children’s sandtrays

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

herapy 37 (2010) 56–64 59

were incorporated into their play. Most children demonstratedsome awareness of their peers through their practice of mirroring orimitating their choice of figurines, their use of water, the way theystructured or placed figurines in their sandtrays, and through theirattentive listening to their peers’ stories. Their play was enhancedas they built on each other’s ideas through this social interaction.The children tended to progress, as is particular to sandplay, in aspiral rather than a linear fashion (Weinrib, 1983/2004). In this way,the same sandtrays can be reproduced from week to week with onlyminor changes and then move to a new level of development as thesandplayer integrates new experiences in their creative process.Further descriptions of the findings highlight the specific details ofthe 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 someneeds)

The pre-symbolic play of children of this first category (n = 3)was characterized by engaging on a sensory level with the sandand a few objects with tactile qualities. There were some indi-cations of functional play, such as moving a bus back and forth.Occasionally, one child would draw simple faces in the sand; how-ever, for all three children there was no sustained creation in thesandtrays, nor any symbolic interactions with the figurines. Waterplayed an important function in attracting and sustaining interestand concentration in the activity.

Communication, which was predominantly non-verbal, wassustained through the medium of sandplay by exploring the prop-erties of the dry and wet sand and of certain tactile objects bysquishing, rolling, and hiding them in the sand with the child, orby playing directly with him by hiding and catching his hands inand under the sand. The autonomy of each child differed, rangingfrom an ability to sustain attention as the workshops progressed,to requiring one-on-one interaction with the therapist/teacher tostimulate joint attention. Children were rarely able to engage withother peers for longer than a few interactions.

Engaging these children in the opening rituals proved more chal-lenging but was facilitated through clear directions supported bypictograms and signing made available by the teachers and spe-cial educators. The closing ritual, on the other hand, because of itsunchanging nature and group dynamic, proved largely popular andtwo of the boys began actively participating in the activity as theybecame more engaged and accustomed to the routine.

Vignette: Sheldon. Sheldon, a 9-year-old boy who was present for all10 sessions, had a tentative initial contact with sandplay. He playedwith some sticky, stretchy worms and was given a small quantityof water to rinse them with. On this first day he merely poured thewater into the sand. His attention was very limited although helined up some marbles a teacher offered him (Fig. 1). Sheldon wasvery restless during the first four sessions leaving his seat to lookfor more water or for something else to do, making loud lamentingsounds and dropping toys on the ground. Although Sheldon’s verbalcommunication was very limited he did ask for water to play witheach week. Water became a means of engaging with the sand, bychanging its properties; as well as engaging him with people as heexpressed his need for it.

Apart from occasionally functionally playing with a school bus,the majority of Sheldon’s play was sensorial. The therapist elabo-

rated upon his play with marbles and bright, sticky creatures, at firstby moving the worms along his arms, which he enjoyed. When histeacher began playing a hide-and-seek game with him by hiding herown hands in the sand and touching Sheldon’s hands beneath it, hisattention was fully aroused and an intense non-verbal interaction

60 L. Lu et al. / The Arts in Psychotherapy 37 (2010) 56–64

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as established. Each subsequent session began with him pouringater in the sandtray and mixing it through burying his hands in

he sand and inviting, through eye contact, for them to be found. Heas then able to play on his own with the worms and marbles for an

xtended period of time (Fig. 2). As he began to experience somehared attention and became more regulated through the struc-ure provided, his affect became more positive and his attentionncreased to the duration of the 45-min workshop. Sheldon, whopoke rarely, began saying “bye-bye” to his sandtray each time heeft, perhaps indicating an emotional investment in the activity ofandplay.

re-symbolic/functional playEach child of this sub-category (n = 4) was able to move from

re-symbolic functional play to the beginnings of symbolic play. Inost cases, the children were limited in their verbal expression.

hey communicated with a few short phrases, some respondedith echolalia, and some were able to use appropriate greetings

uch as “hello, how are you?”. Their participation was much morexpressive during the rituals than in the less practiced context ofalking about their play. Occasionally, indications of shared mean-ng in communication within the play were present. All the childrenn this group benefited from social interaction, mostly with teach-rs and therapists, but also from imitating other children’s work,uch as adding water to the sand. The children’s language becameore articulate during their play as they began to master what theyere doing.

Their initial play was characterized by a sensory exploration ofhe figurines and the qualities of the sand and some functional play.or several weeks the children would resist attempts to extend andxpand on their play, closing circles of communication very quickly.hrough close observation of the play and placing a prompt at theight moment, eventually the point of entry would be found andhe child’s play would move to a deeper level of complexity. Noustained storyline was achieved for this group but rather pieces oftories were created: “the animal drinks from the well”; “The Fordick-up lives at this house”; “the bus was attacked by a crocodile.”

All the boys, through much trial and error in extending andxpanding their play, reached, by the end of the 10 sessions, a levelf representational play conducive to the elaboration of a moreomplex symbolic play and storyline.

ignette: Ryan. Ryan is a timid, gentle 9-year-old boy, who had atrong tendency to respond with echolalia. He was present for all0 sessions. He agreeably took any figurine offered to him but soonut it down and continued functionally playing with a school busr fire truck, which he moved timidly around the sandtray (Fig. 3).

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

For over half of the sessions, Ryan politely rejected all attemptsto expand on his play and repeated back all that was said to him in aquizzical way. He responded with mild interest when the therapistmirrored his play and moved another bus following him in the tray.An entry into his play happened when the therapist elaborated onhis school bus play by placing a house as a destination for the bus tostop. Ryan’s attention was piqued only when a personal connectionwas made as it was suggested that Ryan himself lived in the houseand would be picked up by the bus. When the therapist encouragedhim to look in the figurine bin for a suitable representation for hisschool, he appropriately picked a very large house. Further elabora-tions stimulated his active participation, and spontaneous symbolicrepresentation manifested as Ryan, in a quick and excited manner,picked out animal figures from the figurine bin and identified eachone as his classmates and special educator, placing them aroundthe school in his tray. His teacher mirrored his excitement as henamed the familiar people represented in his sandtray. This activ-ity marked the beginning of Ryan’s spontaneous symbolic play, aswell as a significant reduction of his echolalia during his play. Inthe remaining sandtrays, Ryan began each sandplay with placingthe house, school, and bus in the sandtray. Non-prompted spon-taneous symbolic play began to emerge in such scenes as the busbeing attacked by a giant crocodile, fire trucks and firemen beingadded to the sandtray, skeletons being buried, and so on (Fig. 4).Ryan was able to develop his play after making an initial emotionalinvestment 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.

ymbolic expression

merging symbolic, ritualistic and rigid playThis category of emerging symbolic play (n = 6) illustrates a

roup of children that display the rigidity and ritualistic play, orhat might be termed as perseverative play (Pilewskie, 2007), often

haracterized in children with autism (Wolfberg, 1996). This groupf children often had a difficult time regulating their emotions andheir level of internal organization or disorganization was often rep-esented in the sandplay image. For example rigidity and ritualisticlay was demonstrated by nearly identical placement of figurinesith a repeated set of actions or scripts in each session that had

ittle variation or flexibility. Disorganization was apparent throughhaotic placement or randomly filling the tray full of figurines.

In terms of their level of communication, they would oftenxpress their interest and engagement non-verbally and were ableo say a few words or a sentence to describe their image or storyhen prompted. Interactions during the sandplay were limited

o a few exchanges, as it was difficult for the teachers and facil-tators to find a point of entry into the play or ask questions tohe child, because of the single-focused quality of the play. Whenhe therapist was able to enter into the play, such as playing theeferee in a scripted sports game, it was possible to use the plays a form of emotional co-regulation. However, for all the chil-ren in this category, they were often quite social and expressiveuring the opening and closing ritual, demonstrated by smiling,aking eye contact, and initiating appropriate answers to our inter-

ctive themes and imaginary play. In their symbolic expressionshey would create simple storylines and symbolic themes such asggression in a sports game, or nurturance through an interactivecene of figurines set amongst home furniture and food; however,o further verbal description would be made.

ignette: Mario. Mario is a 10-year-old boy who appeared smiling,ontent, and interactive with his peers, teachers, and facilitators,specially during the opening and closing ritual. However, from therst session Mario’s play in the sand tray was characterized by rigidlacement of figurines between two goal posts playing “sports.”hroughout the play he seemed to perseverate by remaining fixednd focused on placing his “team” of players in the tray. He wouldot respond to prompts or questions, nor was he interested in theandplay images of his peers and would often resist finishing hislay by the end of the session. When he did respond to our questionsf what was happening in the tray he would say “They are playingports” (Fig. 5).

Mario would ritualistically repeat this play in every session,radually modifying the play by adding animals, cars, play money,nd flags in the tray, and often there were so many figurines thatore and more would be placed outside of the sandtray. Mario

herapy 37 (2010) 56–64 61

made attempts towards symbolic interaction by placing the fig-urines facing each other; however, his rigid play did not providehim with the fulfillment of symbolic engagement. Yet in the lastsession Mario appeared to satisfy this need by uncharacteristicallyasking to be placed in the spot of his friend George, with whom hehad interacted in the previous session. He imitated George’s play byhaving the figurines “bounce” off the sides of the box like a wrestlingring to attack each other, while also borrowing English phrasesfrom George, like excitingly calling out “1-2-3” and “Oh my God”as the figurines would launch an attack. Mario began the sessionsplaying in a ritualistic and rigid manner; however, he respondedto his desire for greater symbolic engagement through imitationand borrowing another play script in order to move beyond hisperseveration in his play. Despite the repetition and rigidity ofhis sandplay images, Mario demonstrated an untapped capacityfor symbolic expression and engagement in the play and wouldhave probably benefited from a longer series of sessions in order toelaborate his play.

Symbolic representation and the beginning of storytellingIn this group of children (n = 7), the sandplay images are richer

in symbolic representation and through the process the childrenbegan to demonstrate a better capacity to link elements into arudimentary storyline. They had varying degrees and capacities ofcommunication, some were able to verbally describe their sandplayimages 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 interactduring the exercises and enjoyed telling and showing their sand-play stories to their peers at the end of the session. Three of thechildren actively played in each other’s sandtrays and told sto-ries together. Many of them would incorporate figurines or storiesthat would be inspired from the exercises or from observing otherchildren’s story images.

The symbolic themes in the sandplay of this group rangedin complexity and included age-appropriate themes of aggres-sion/fighting/death/fear; accidents and rescue stories; sharing andnurturance; repairing when characters were hurt; and activitiesfrom their daily lives—school, eating, sports, and birthdays. In thisgroup there was a range of different intellectual abilities, whichreflected the degree of complexity that children were able to pro-duce in their symbolic play. The story telling was not alwayscoherently organized into a recognizable story format with a begin-ning, middle (conflict/issue), and end or resolution, but the storieswould often closely approximate this format. This group of chil-dren would be able to respond to play invitations from their peers,teachers, or facilitators with common shared meanings and to elab-orate upon them to continue the play. Through the progress of eachsession, it seemed that the majority of children were able to elab-orate their play by adding more elements and investment in theirstories.

Vignette: Emile. Emile is an 11-year-old boy, who was timid, calm,and attentive throughout the sessions, and who liked to engage inthe exercises and activities. He communicated, often with prompt-ing, in short, concrete phrases, seemingly self-stimulating on wordsat the end of his sentences that he would accentuate with an inflec-tion or repetition. In his first and second session, he demonstratedelaborated functional play when he lined up the houses aroundthe sandtray and repeatedly moved a school bus back and forthon the L-shaped corridor he created (Fig. 6). He allowed the thera-

about his story, he said “The school bus is making his rounds in theneighborhood houses” and would not elaborate further.

However, by the third week, a shift in Emile became evident ashe was influenced by the imaginary play theme of animals in our

62 L. Lu et al. / The Arts in Psychotherapy 37 (2010) 56–64

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

pening ritual. He initially began playing with the school bus, butoon became more invested in creating a forest scene of animalsnd plants. Initially, he was very timid to tell his story, but withrompting from his peers he proudly described his story image stat-

ng “The sun and stars are looking at the springtime. There are birdsnd caterpillars in the forest. There are birds in nests in the forest.here is a fly buzzing (making the sound)”. Although he repeated thispringtime image for another two sessions, it appeared that Emileecame more influenced by the imaginary play in the rituals andlowly began incorporating people and creating elaborated scenesFig. 7). As his stories developed, Emile gained the confidence andesire to recount his stories, often going beyond the time limit avail-ble. By the end of the ten sessions, Emile was able to elaborate hisymbolic play by incorporating more interactive elements, whilelso beginning to link them coherently into a storyline.

ymbolic themes organized into story formThis last category regroups children (n = 5), who demonstrated

he capacity to create spontaneous, complex scenarios involvinguch detail, drama, and a mostly coherent storyline. Emotional,

oncrete, and magical thinking were present in their sandplay.any themes were developed expressing loss, intrusions, compe-

ition, conflict resolution, and the establishment of boundaries.This group had a higher level of language mastery, and

xpressed relatively coherent stories in complete sentences.lthough they had the expressive vocabulary to indicate emo-

ions, such as fear or sadness, affect was rarely present in theirxpressive tone.

As demonstrated in sandplay with children within other class-

oom settings (Lacroix, 2002), three children appeared to useandplay to work through personal struggles, such as difficultiest home, frustrations with physical limitations, or personal tensionith 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. Childrenof the 4th and 5th category were very appreciative audiences fortheir peers: they laughed, asked questions, expressed admirationas well as compassion and sadness. In a very few cases, irritationor mockery was expressed as well. Children of this group partici-pated actively in rituals often offering personal anecdotes, creatingcollective stories, and participating in pretend play such as hik-ing through a mountain and camping in a cave. Themes from theopening ritual were often present in the sandplay.

In summary, children of this sub-group were able to expresscomplex emotional content and link several ideas into a relativelycoherent storyline. The sandplay offered them a medium to elabo-rate on this capacity, in some cases write stories from their sandplay(often for the first time), as well as providing them a medium tointeract with peers and teachers.

Vignette: Isaac and Jean-Claude. Isaac is a thoughtful, articulate 11-year-old boy who often verbalized his actions of play with privatespeech. Like many of his classmates, he initially enacted a gameof soccer. By the third session, Isaac stopped himself midway set-ting up another game saying, “no, I want to tell a story,” choosingto let go of the familiar sports script. He then created a dramaticstory involving kidnapping, detective work, and supernatural inter-ventions, and he connected with the emotions of his charactersrelating, “He did not find his grandmother and began to cry” (Fig. 8).

Role-playing and pretend imaginings involving object substi-tution and symbolic thinking were demonstrated in subsequentsandplays created with his fellow classmate Jean-Claude, a 12-year-old boy with a keen sense of humor who often initiated invitationsto play with Isaac. Isaac solved the problem of having Jean-Claudeidly wait while he narrated the story, by giving his classmate therole of cameraman. Isaac turned a mirror upside down and the holein the handle became the lens through which either child could filmthe other’s story. Jean-Claude, although feeling a bit self-consciousat first, “filmed” Isaac’s story and, in this manner, his symbolic playwas enhanced (Fig. 9). Isaac, through this game, began to expressa meta-cognition of play in the sense that he was able to step outof his play, observe his play and attempt to share his symbolic playwith his peer.

The boys complemented each other as Isaac contributed elabo-rate storylines that tended to get bogged down in detail whereas

Jean-Claude added drama and realism through such devices as rob-beries and assigning more logical outcomes to the stories, such asthe police arriving to assist the victims. Some of the themes ofthe stories sparked interesting discussion about their knowledge

L. Lu et al. / The Arts in Psychot

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

f religious practices or preferred movies. The medium of sand-lay allowed these higher-functioning children with autism a spaceo interact and focus joint attention on a creative activity whileupporting and stimulating the symbolic interactions in their play.

iscussion

As pleasure and enjoyment are essential characteristics of playWolfberg, 1996), it is noteworthy that the children with ASD whoarticipated in this program enjoyed the sandplay process. Indeed,andplay was originally devised as a safe, free, and unfocusedpace for children to play (Mitchell & Friedman, 1994). As such,andplay, adapted as a semi-structured creative intervention forhildren with ASD, provided a multi-layered support for play andreative expression. The sand and the diverse array of figurinesupported sensory and symbolic play; the individual sandtrayselimited a protected space; while social interaction and expressiveommunication was encouraged through the sharing of figurines,he imaginary play in the rituals, and the storytelling exchanges.

ithin the structure and framework of the rituals and sandplay,hildren were given a non-goal-oriented and creative space fornstructured play that encouraged symbolic development at theirwn rhythm. This is an important condition for supporting cre-tivity that is absent in adult directed activities typically practicedithin programs for children with ASD in schools. This comple-entary space to the regular academic program allowed freedom

or children to return to sandplay images and themes on a weeklyasis without the expectation to achieve a set academic goal.

Children responded to this semi-structured sandplay activityith initial tentative involvement, yet over the course of the 10eeks the increased engagement and investment in the activity

upported their developmental skills in communication, socializa-ion, and symbolic elaboration. Children tended to work in a spiralather than a linear fashion, staying with the same themes anduilding and expanding, with growing flexibility upon their playapacities over the course of the program. Children could addressheir particular limitations pertaining to the foundations of relat-ng, communicating, and thinking (Greenspan & Wieder, 2006) thatad not been previously mastered, such as sensory exploration,ngaging and relating, sharing attention, and purposeful emotionalnteraction.

It appeared that for the children in the pre-symbolic level of

xpression, the sensory tactile aspect of the sandplay encour-ged motor skills development and early social play, while alsoncouraging emotional regulation. Therapists, teachers, and spe-ial educators played the role of supporting emotional regulation asell as two-way engagement by enhancing and expanding on sen-

herapy 37 (2010) 56–64 63

sory exploration and functional play through making an emotionalconnection to the child’s experience. According to developmentaltheories of play (Greenspan & Wieder, 2006; Wolfberg, 1996), achild’s ability to engage in higher levels of spontaneous communi-cation, socialization, and symbolic elaboration is based on sharedattention and sustaining two-way pre-symbolic communication.The sandplay intervention demonstrated that it could be a mediumused to develop the core deficits of children with autism, while atthe same time supporting children operating at higher functionalemotional levels within the same classroom setting.

Children expressing at a symbolic level of play and story devel-opment appeared to benefit from the sandplay intervention byhaving the visual figurines and objects to sustain the developmentof their emotional thinking and linking abstract ideas into coher-ent storylines. As children became familiar with the medium andgained confidence in creating sandplay images, they became moreat ease with interacting with each other, listening to each other, andbeing able to narrate their stories for their classmates and teachers.The children that had the least progression in this category werechildren showing rigid, ritualistic, and perseverating tendencies intheir play, which made it challenging for therapists to intervene andfind a point of entry into their play. However, just as the other chil-dren in this category who functioned at higher levels of symbolicexpression benefited from the shared attention of the sandplay andsocial interaction from peers and adults during the intervention,it seems promising that this group of children could also bene-fit from more sandplay sessions to develop theses skills of play.More research is necessary to investigate how sandplay could pro-vide the medium and social interaction to interrupt perseverativeplay; however, it seems to support current theories (Sherratt, 2002;Wolfberg & Schuler, 2006), that symbolic play can be enhanced bywatching or interacting with peer models.

Sandplay was adapted as a group creative play support programusing a relational approach to play (Greenspan & Wieder, 2006) ina semi-structured format, in order to provide the structure thatis the cornerstone of programs for children with ASD (NationalResearch Council, 2001), while also providing an open-ended, cre-ative space to support spontaneous communication, socialization,and symbolic play. Sandplay offered a unique combination of sen-sory stimuli (sand, water, colorful, and textured objects), the rawmaterial for story making (figurines, building materials), contain-ment and a free creative space, as well as social contact andstimulation. In this sense the structure and materials supportedthe relational approach elaborated in Greenspan’s (2006) Floortimemethod, but structured and supported the ability to work with asmall group of children with varying degrees of developmental abil-ities. Sandplay adds a relational triangular component, in the sensethat the interaction is through the sandplay, whereas Floortime isdesigned as an interpersonal and open-ended dynamic.

The use of an action-research methodology provided the frame-work that allowed for teachers’ input into the program andadjustment by the therapists to the various developmental needsof the children. Teachers were invaluable contributors as theirknowledge of the children helped to identify types of play thatthey enjoyed, such as Sheldon’s hide-and-seek play, and providedinsight into how the children’s play reflected their interests or per-sonal experiences.

The teachers’ introduction of a story structure around the playprovided positive support, for certain students, for organizing thenarration of their sandplay. Thus, teachers’ goal of stimulatingcreative writing harmonized well with the overall objective of

stimulating symbolic elaboration and communication. However, itappeared also that for some children this extra structure createdpressure to conform to a certain level of storytelling they had notyet attained. The use of a minute timer provided by another teacherto delimit the storytelling appeared to meet the children’s need

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4 L. Lu et al. / The Arts in Ps

or structure without too much constraint or expectation. Furthernvestigation is needed to evaluate the impact of restraining theumber of figurines available for certain children with ASD, specif-

cally those with the tendency to perseverate. In some cases, likehe practice of limiting the amount of water provided, this wouldppear to be recommended, in other instances providing regulationhrough interaction with the children through the play (providingraffic lights, police, or referee figures) would seem sufficient, andn the case of Mario, he appeared to interrupt his own persever-ting play by imitating another child’s play that he found moretimulating.

Further research is needed to replicate this work and to confirmhe benefits of providing, through such a program, a more creative,ess structured, and non-goal oriented space to meet existing edu-ational goals for children with ASD. Once the benefits of sandplayo support creative symbolic thinking in children with ASD haseen investigated, further research is needed to evaluate to whatxtent the program can be transferred to teachers to implementnd how much training, external support, and supervision is nec-ssary to successfully disseminate the program in schools. Finallyurther study is encouraged to see how sandplay adapted as a cre-tive group activity within the classroom can be applied also tohe needs of other children who may experience other social ormotional difficulties.

In conclusion, sandplay adapted to children with ASD appearso provide the potential of enough structure around a free andnfocused creative space to support the developmental skills ofommunication, socialization, and symbolic elaboration. Childrenespond and interact with the medium at their individual develop-ental level, which makes it an ideal medium to be used in a school

etting for classrooms with various developmental needs.

cknowledgements

The research findings from this school intervention were basedn an action research investigated by school psychologist Déogra-ias Bagilishya, professor and art therapist Louise Lacroix, fromoncordia University, along with the Youth Mental Health TeamCSSS), and was funded by the Quebec Ministry of Education, Sportsnd Leisure. We would also like to thank the students, parents,eachers, special needs educators and staff at École Simone-esjardins for their participation and support in this research.

ppendix A. Supplementary data

Supplementary data associated with this article can be found, inhe online version, at doi:10.1016/j.aip.2009.09.003.

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