Qualitative and quantitative pretend play and their predictors in children with autism spectrum disorder: A path-analysis study

Children with autistic spectrum disorder (ASD) often have difficulties in both qualitive and quantitative pretend play. Theory of mind (ToM), symptom severity, and verbal comprehension appear to be potential correlates of pretend play. However, the underlying relationships of these correlates to pretend play remain unclear. Therefore, we applied path analysis to explore the relationships among these variables in children with ASD. A total of 151 children with ASD aged 3 to 12 years and their caregivers participated in this study. Children's pretend play, ToM, verbal comprehension, and symptom severity were respectively assessed with Child Initiated Pretend Play Assessment, Theory of Mind Task Battery, The verbal comprehension index of Wechsler Intelligence Scale for children-Fourth Edition or Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition, and Childhood Autism Rating Scale. The results showed that the SEM model fit well. The quality and quantity of pretend play were correlated to each other. ToM was positively related to qualitive and quantitative pretend play. Moreover, symptom severity was directly related to quality of pretend play; verbal comprehension was indirectly linked to quantity and quality of pretend play through ToM and symptom severity. In conclusion, our study reveals the underlying relationships of ToM, symptom severity, and verbal comprehension to quantitative and qualitative pretend play in children with ASD. This study both clarifies the important factors of qualitative and quantitative pretend play and provides suggestions to improve pretend play in children with ASD.