Pretend play performance across support levels in autistic children: a mixed methods study

Pretend play is an important indicator of child development and may provide clinically relevant information about how autistic children organise, sustain, and share play. However, little is known about how pretend play varies across the three autism support levels. To investigate and describe pretend play performance across the three support levels in autistic children. This mixed methods study included 42 autistic children aged 4 to 7 years, evenly distributed across DSM-5-TR Levels 1, 2, and 3 (14 per group). Pretend play was assessed using the Child-Initiated Pretend Play Assessment 2 (ChIPPA2). Quantitative analyses included raw scores for Percentage of Elaborate Play Actions (PEPA), Number of Object Substitutions (NOS), Number of Imitated Actions (NIA), supportive and non-supportive indicators of play, and Enjoyment in Play Scale scores. Group differences were examined using Kruskal-Wallis tests and Quade’s rank analysis of covariance controlling for age and sex. The qualitative component was based on narrative observational records derived from video-recorded sessions and analysed using qualitative content analysis. Findings were integrated during interpretation. Significant differences were found across the three support levels for PEPA scores, NOS symbolic and combined scores, NIA scores, supportive and non-supportive indicators of play, and enjoyment in play. Children in Level 1 showed the most complex pretend play performance, children in Level 3 the least complex, and Level 2 an intermediate profile. Qualitative analysis identified four thematic categories: symbolic elaboration of play, social engagement during play, reduced play engagement and discontinuity, and concrete, repetitive, and sensory-perceptual engagement with materials. Symbolic play was more sustained and elaborated in Level 1, less integrated in Level 2, and brief and circumscribed in Level 3. In contrast, concrete, repetitive, and sensory-perceptual engagement with materials was especially evident in children with higher support needs. Integrated findings showed convergence between lower quantitative performance and less sustained, less socially shared, and less symbolically organised play. Pretend play performance varied across the three support levels in autistic children. The ChIPPA2 provided clinically meaningful information about the organisation, continuity, enjoyment, and social sharing of play, and may support more individualised assessment and intervention planning.