942850

research-article2020
TECXXX10.1177/0271121420942850Topics in Early Childhood Special EducationSaral and Ulke-Kurkcuoglu

Reports of Original Research

Topics in Early Childhood Special Education

Using Least-To-Most Prompting to

1­–17
© Hammill Institute on Disabilities 2020
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DOI: 10.1177/0271121420942850
https://doi.org/10.1177/0271121420942850

of Pretend Play in Children with Autism tecse.sagepub.com

Dincer Saral, MA1 and Burcu Ulke-Kurkcuoglu, PhD2

Abstract
We examined the effects of the least-to-most prompting (LTM) procedure with contingent imitation (CI) on increasing the
frequency and diversity of pretend play in children with autism spectrum disorder (ASD) using a multiple probe across toy
sets single-case research design. Three children with ASD aged 5 to 6 years took part in the study. LTM was functionally
related to increases in the frequency and diversity of children’s pretend play. Novel pretend play behaviors, sequences, and
vocalizations also increased for all children. Importantly, all children maintained the target skills 1, 2, and 4 weeks after the
intervention and generalized them across their homes, mothers, and different toys.

Keywords
autism spectrum disorder, pretend play, system of least prompts, least-to-most prompting, contingent imitation.

Pretend play is often reported as a precursor for advanced
thinking, reasoning, and using symbols to represent related
actions (Morelock et al., 2003; Piaget, 1962; Vygotsky,
1967). Moreover, pretend play is related to communication,
empathizing, and interacting with peers (Ulke-Kurkcuoglu,
2015). Pretend play is a functional goal, which represents a
category of behavior in Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM-5; American
Psychiatric Association, 2013) and diagnostic measures
such as Autism Diagnostic Observation Schedule, Second
Edition (ADOS-2; Lord et al., 2012). Children with autism
spectrum disorder (ASD) display deficiencies in spontane-
ous and object play in a nonliteral manner (Barton et al.,
2020; Jarrold et al., 1996). Furthermore, they consistently
exhibit less frequent and varied pretend play behaviors than
their typically developing peers (Barton, 2015). In fact,
deficiencies in pretend play are early markers of ASD
(Wetherby et al., 2004). Pretend play behaviors in children
with ASD are often disconnected, different in form, and
lack diversity when compared with the pretend play of chil-
dren with typical development. Given the prevalence of
pretend play in young children, delays in pretend play
behavior likely result in limited social and communication
opportunities and can have lasting developmental impact
(Wolfberg & Schuler, 1993).
Various interventions, such as least-to-most prompting
(LTM), have been examined to teach pretend play skills
to children with ASD (Barton et al., 2020; Barton &
Wolery, 2008). LTM consists of at least a three-level
prompt hierarchy in which the least intrusive prompt is
followed by more intrusive prompts (Tekin-Iftar &
Kırcaali-Iftar, 2013). Many studies conducted with indi-
viduals with ASD have shown that LTM is effective in
teaching various skills such as communication skills (Xin
& Leonard, 2015) and play skills (Ulke-Kurkcuoglu,
2015). LTM might be particularly effective for teaching
pretend play because it (a) lets the child respond indepen-
dently, (b) minimizes the possibility of overreliance on
prompts, (c) can be embedded into play contexts, and (d)
supports an effective interaction between the child and
their playmate (Ulke-Kurkcuoglu, 2015).
Barton and colleagues (2020) conducted a systematic
review of the play intervention literature and identified 27
intervention studies focused on teaching object play to chil-
dren with disabilities. Their review highlighted two impor-
tant results. First, the intervention is more effective when
adult prompting is particularly embedded into the context
of LTM procedure. Second, LTM does not interrupt the
play interaction, which lets the child produce spontaneous
play behaviors. Furthermore, the adult can easily fade the
prompts that can be selected and adapted based on the
child’s performance and learning history (Barton, 2015).
Although researchers have used LTM to teach pretend play
1
Hacettepe University, Ankara, Turkey
2
Anadolu University, Eskisehir, Turkey
Corresponding Author:
Burcu Ulke-Kurkcuoglu, Research Institute for Children with Disabilities,
Anadolu University, Yunus Emre Campus, Eskisehir 26470, Turkey.
Email: bulkekurkcuoglu@anadolu.edu.tr
2 Topics in Early Childhood Special Education 00(0)
(e.g., Lifter et al., 2005), researchers in only five studies
taught four categories of pretend play using LTM (Barton,
2015; Barton et al., 2013; Barton & Wolery, 2010; Kasari
et al., 2006; Ulke-Kurkcuoglu, 2015), four of which mea-
sured sequences and vocalizations (Barton, 2015; Barton &
Wolery, 2010; Kasari et al., 2006; Ulke-Kurkcuoglu, 2015).
Researchers in only three of these five studies evaluated
children’s pretend play behaviors in terms of whether they
had been exhibited previously within each play session (i.e.,
a repetition of previous play behavior; Barton, 2015; Barton
& Wolery, 2010; Kasari et al., 2006). Finally, researchers
used contingent imitation (CI) during play in three of the
five studies (Barton, 2015; Barton et al., 2013; Barton &
Wolery, 2010).
Barton developed a taxonomy consisting of four catego-
ries to operationalize pretend play: (a) functional play with
pretense (FPP), (b) object substitution (OS), (c) imagining
absent objects (IAO), and (d) assigning absent attributes
(AAA). Barton’s taxonomy also referenced characteristics
of play including play diversity, sequences, and vocaliza-
tions related to play. Sequences are at least two pretend play
behaviors related to a play theme. Sequences are significant
because they are a marker of a more advanced pretend play
behavior repertoire and provide further evidence for the
inference of pretend play. Vocalizations are expressions that
define and confirm a pretend play behavior and can assign
roles to an object, assign attributes to a child, or signal the
nonliteral nature of a behavior (Jarrold et al., 1996). Some
pretend play behaviors, especially AAA, usually involve
vocalizations (e.g., stops the tractor and says, “Broken”).
Vocalizations can include the words and action sounds
children make during play and often provide further indica-
tion that the child is making an inference.
CI is defined as imitating vocal or motor behaviors
immediately following the child’s production (Barton,
2015). CI can be used to obtain and secure attention, which
might be particularly important for children with ASD who
are known to be easily distracted (Pascualvaca et al., 1998).
CI can be used to direct the child’s play interactions and
to improve the child’s attention to the adult or context.
Moreover, CI encourages the child to attend and maintain
their attention and engagement in the activity. CI is also
reported to increase social vocalizations and play complex-
ity among children with ASD. Barton (2015) found that the
use of LTM with CI by teachers was effective in increasing
the frequency and diversity of pretend play behaviors in
children with disabilities and children maintained and gen-
eralized the acquired skills across materials and settings.
Additional replications are warranted to establish a compre-
hensive understanding of the relation between LTM and CI
and children’s pretend play.
We examined the effects of the LTM procedure with CI
to increase the frequency and diversity of pretend play,
including all categories and characteristics in children with
ASD. The following research questions guided the study:
Research Question 1: Is LTM with CI effective in
increasing the frequency of pretend play and vocaliza-
tions among children with ASD?
Research Question 2: Is LTM with CI effective in the
maintenance of behaviors and vocalizations after 1, 2,
and 4 weeks?
Research Question 3: Is LTM with CI effective in the
generalization of behaviors and vocalizations across
different settings, materials, and adults?
Research Question 4: Is LTM with CI effective in
increasing behavioral diversity, in terms of different
behaviors and vocalizations, among children with ASD?
Research Question 5: Does LTM with CI increase cat-
egorical diversity, in terms of pretend play categories, in
children with ASD?
Research Question 6: Does LTM with CI increase the
frequency and categorical diversity of novel pretend
play behaviors and vocalizations and ensure mainte-
nance and generalization in terms of frequency?
Research Question 7: Does LTM with CI increase the
length and number of sequences among children with
ASD?
Research Question 8: What are the opinions of the
children’s mothers and teachers about the study?
Method
Participants
Three boys aged between 63 and 68 months with ASD
participated in the study. The participants attended a devel-
opmental support unit for individuals with disabilities affil-
iated to a state university for 3 hr a day on weekdays and
attended public preschool inclusive classrooms for the
remainder of the day.
Three measurement tools were administered to describe
the participants. First, Gazi Early Childhood Assessment
Tool (GECAT) was used to determine developmental levels
of the participants. GECAT focuses on four developmental
domains of Turkish children aged between 0 and 6 years.
There is a high correlation between the GECAT and the
Denver Developmental Screening Test scores. The partici-
pants’ score on GECAT indicated that they were below the
normal level of a 60-month-old child in regard to psycho-
motor and cognitive development and below the level of
a 48-month-old child in terms of language and socio-­
emotional development. To determine the severity degree
of autism of the participants, Gilliam Autism Rating
Scale–2, Turkish Version (GARS-2-TV) was administered.
The GARS-2-TV is used for various purposes such as
Saral and Ulke-Kurkcuoglu
Table 1. Descriptions of Child Participants.
GECAT developmental age range (months)
Child Diagnosis Gender Age PMD CD
Bora ASD Male 63 49–60 49–60
Can ASD Male 68 49–60 49–60
Deniz ASD Male 68 37–48 49–60
Note. GECAT = Gazi Early Childhood Assessment Tool; GARS-2-TV = Gilliam Autism Rating Scale–2, Turkish Version; PMD = psychomotor
development; CD = cognitive development; LD = language development; SED = socio-emotional development; IS = Intelligence Scale; ASD = autism
spectrum disorder.
screening and identifying Turkish individuals with ASD aged
from 3 to 23 years. The scale includes subtests on stereo­
typical behaviors, communication, and social interaction.
All the children’s scores on the GARS-2-TV indicated a
possibility of autism. The Stanford–Binet Intelligence Scale
was used to calculate the intelligence scores of individuals
with ASD. A certified special educator who was different
from the implementer implemented the tests. All partici-
pants scored in the high-functioning range (see Table 1).
The following inclusion criteria were used: (a) having a
doctor certified ASD diagnosis received from a child psy-
chiatry department of a university or public hospital, (b)
having the Individualized Education Program (IEP) goal(s)
related to pretend play, and (c) exhibiting fewer than four
pretend play behaviors and three vocalizations during a
10-min play-based session with an adult. Furthermore, the
prerequisite skills were identified as being able to (a) imi-
tate gross and fine motor skills, (b) engage in a 5-min play
activity, (c) imitate vocal expressions, (d) perform simple
vocal instructions, (e) form at least two-word sentences, (f)
exhibit functional play behaviors, and (g) have adequate
gross and fine motor skills to perform pretend play behav-
iors intended to be taught. All prerequisite skills were eval-
uated by the implementer.
Implementer
The first author conducted the experimental sessions, while
the second author designed the study. The first author was a
master’s degree student in applied behavior analysis and
ASD. He had a 2.5-years of experience working with pre-
school-age children with ASD. The second author had a
PhD degree in special education and 17 years of experience
in working with children with ASD.
Setting
The study was conducted in an assessment room in a devel-
opmental support unit affiliated with a university in Turkey.
The room was a 6 × 6-m carpet-covered area and furnished
with an armchair, a sofa, two tables, a clock, three chairs,
3
LD SED GARS-2-TV Stanford–Binet IS
31–36 37–48 62—Possibility of autism 116
37–48 37–48 75—Possibility of autism N/A
37–48 37–48 66—Possibility of autism 117
and a window mirror on the wall. The implementer sat on a
chair and the child sat on the sofa, facing the implementer
with a table of toys between them. The generalization ses-
sions were conducted in each child’s home. During general-
ization conditions, non-study toys were removed from the
room and the child and his mother sat face-to-face on the
floor with the toys.
Materials
The implementer conducted interviews with teachers
regarding child toy preferences, reviewed toy sets used in
previous studies, and made nonparticipant classroom obser-
vations to develop the toy sets. Three junk toys were
included in each toy set to elicit OS behaviors and dupli-
cates of all toys were used to support CI. The instructional
toy sets were as follows: (a) a playhouse toy set (PHS; fig-
ures of a mother, father, and child; a spoon; a piece of pizza;
a cup; a plate; a kitchen stove; a block; a ribbon; and a card-
board box), (b) a farm toy set (FTS; figures of a farmer,
cow, and goat; a shovel; a stable; a plant; a fence; a tractor
with a trolley; a toothbrush; a sponge; and a playdough
box), and (c) a fire station toy set (FSS; figures of a fire-
fighter, human, and dog; a hose; a fire station; a gas pump;
a fire truck; a metal box; a LEGO brick; a helmet; and an
eraser). The generalization sessions were conducted with
toys of different sizes and colors from those used in the
instructional sessions.
Dependent Variables, Response Definitions, and
Measurement
The following dependent variables were measured: prompted
pretend play behavior, same pretend play behavior (repeti-
tion of a previous pretend play behavior no matter whether it
is novel or not), novel pretend play behavior (a pretend play
behavior not taught and never prompted by the implementer
and generated by the child himself), sequences (more than
one pretend play behavior related to the same play theme
and occurring in 5 s), prompted vocalization, unprompted
vocalization, same vocalization, different vocalization, and
4 Topics in Early Childhood Special Education 00(0)
novel vocalization. Specific pretend play behaviors and
vocalizations were selected based on the previous observa-
tions in classrooms and the behaviors of a typically devel-
oping 4-year-old child who was asked to play with the final
toy sets. The examples of pretend play behaviors and
vocalizations are presented in Table 2.
The frequency of each dependent variable was recorded
using timed event sampling. The frequency of pretend play
was defined as the number of unprompted pretend play
behaviors (pretend play behaviors exhibited before the
implementer’s prompt; for example, the child feeds a goat
with a cup, which has not been previously exhibited in the
session by the implementer). Two aspects of the diversity
of pretend play behaviors were measured. First, behavioral
diversity was defined as different pretend play behaviors (a
pretend play behavior that has not occurred previously in a
session no matter whether it is novel or not). Different pre-
tend play behaviors could be among the targeted play
behaviors or the ones that the child generated himself.
Second, the distribution of pretend play behaviors into four
categories of pretend play was defined as categorical
diversity.
Experimental Design
A multiple probe design across toy sets was used to examine
the effects of the intervention (Gast et al., 2018). Unprompted
pretend play behaviors and vocalizations in the intervention
sessions were the primary data used to make decisions
regarding condition changes. The number of different pre-
tend play behaviors and vocalizations were secondary mea-
sures. We used visual analysis to make formative designs
about condition changes and summative decisions about
functional relations. We used visual analysis to examine the
frequency and diversity of pretend play behaviors and vocal-
izations. We examined the level, trend, variability, overlap,
immediacy of change, and consistency of data.
General Procedure
The implementer conducted the pilot intervention sessions
with a different child from study participants to predeter-
mine any possible flaws and to put materials into the final
form for experimental sessions. When the implementer
reached the 90% procedural fidelity, the experimental ses-
sions commenced.
Baseline/probe sessions. During probe conditions, 5-min
probe sessions were conducted daily. During these ses-
sions, the implementer did not prompt any behaviors but
used CI to build a play interaction and to keep the child’s
engagement in the play activity. When the child exhibited
any pretend play behaviors, the implementer used verbal
expressions related to the behavior (e.g., “Oh look, her
stomach’s got big!”). The implementer provided social and
verbal praise for each child’s cooperation at the end of the
sessions.
Intervention sessions. These were the same as baseline/probe
sessions except that the implementer also used LTM. These
sessions lasted until the total number of all target pretend
play behaviors (n = 20) were exhibited either with or with-
out prompts. The criterion for the target behaviors for each
child was determined by multiplying the highest number of
behaviors exhibited at baseline by 5. The implementer used
LTM with a three-level prompt hierarchy (independent
level, model and verbal prompts, and full physical and ver-
bal prompts). In the verbal prompt condition, the imple-
menter delivered a verbal model prompt (e.g., “wee woo”).
The implementer started the intervention and waited for 15
to 30 s by contingently imitating and observing the child.
When the child did not engage in any pretend play behav-
iors during a 15 to 30 s time window, the implementer pre-
sented model and verbal prompts to a behavior related to
the toy(s) that the child had touched, held, and looked at
previously. If the child did not imitate the model or display
a novel pretend play behavior, the implementer used the
final prompt level, full physical and verbal prompts. The
implementer also narrated the child’s play while contin-
gently imitating (e.g., fence as if a blanket, “It’s soft and
warm!”) pretend play behaviors.
In these sessions, if the child exhibited a pretend play
behavior in a pretend play category (e.g., OS), the imple-
menter tended to prompt a pretend play behavior in the
other categories (e.g., AAA). The decisions on what cate-
gory of pretend play to prompt were in-the-moment and
appropriate to the context. Second, pretend play behaviors
were determined and organized in sequences. Third, when
the child attempted to exhibit the same behavior for the
fourth time within a session, the implementer interrupted
his attempt and prompted another pretend play behavior
immediately to increase different pretend play behaviors.
Maintenance and Generalization Sessions
The maintenance sessions were carried out 1, 2, and 4
weeks after the intervention conditions ended. Maintenance
conditions were the same as baseline/probe conditions. The
generalization sessions were conducted before and after the
intervention as pre- and post-test across adults, settings, and
materials in each child’s home by his mother, using toys of
different sizes and colors from the instructional sets. For
example, the fire station was green, not red, as in the instruc-
tional toy set. Therefore, the toy sets were similar in func-
tion but different in form. The mothers did not prompt any
behaviors but used CI throughout the 5-min sessions.
 Table 2. Examples of Target (Taught) and Novel Pretend Play Behaviors and Vocalizations.

Categories Pretend play behaviors and vocalizations targeted to teach Examples of novel pretend play behaviors and vocalizations
Play house toy set
AAA Picks spaghetti from pan and says “It’s Lays the figure down and says Shakes a figure fast and says “I got Puts a figure in a cardboard box and
burnt!” “sleeping.” dressed.” says “Studying a lesson.”
IAO Connects index finger with thumb and Moves hand up and down over pan Moves his hand as if putting yogurt in Says “Ugh, it’s night” and closes
moves round saying “locking door.” saying “adding salt.” a cup and says “I’m putting yogurt.” cardboard box with a block.
OS Puts ribbon in cardboard box saying Puts cardboard box and says “It’s my Puts a cardboard box on a table and Puts a pizza on a table and says “It’s
“putting spaghetti.” school.” says “It’s my elevator.” bread now.”
FPP Feeds figure with pizza saying “nom Moves figure up and down in walking Puts a pizza on a plate and says “The Turns up temperature on the oven
nom.” motion. pizza’s ready.” after putting the pizza in.
Farm toy set
AAA Stops tractor and says “Ouch, Puts up stable and says “cow’s Has a figure jump on an eraser and Says “The farmer feels sleepy” and lays
broken.” awake.” says “Higher! Higher!” it down on table.
IAO Moves hand as if picking fruit on tree. Moves semi-open hand over cup Touches a goat’s face and says “I’m Puts empty hands to goat’s mouth and
saying “pouring water.” applying face cream.” says “I’m feeding it with fruit.”
OS Uses fence as if a blanket. Stirs toothbrush in cup as if a spoon. Uses fetch as if wings of a plane. Uses a sponge as if pasta.
FPP Toothbrush in back and forth brushing Moves shovel between tractor and Puts the goat in a tractor trolley and Rubs a goat with a sponge.
motion to cow’s mouth. table as if picking up leaves. says “I catch it.”
Fire station toy set
AAA Shakes human figure and says “save Has firefighter walk and says “Let’s Rotates a figure’s leg and says “Its Has a figure walk saying “Going to the
me!” save him.” leg’s broken.” doctor.”
IAO Moves cupped palm between table Holds palm down over metal box and Touches fire truck as if fixing a flat Suddenly stops moving fire truck and
and fire truck as if carrying water. says “it’s burning.” tire and holding a repair kit. says “Red light.”
OS Moves hose on table as if a snake and Puts eraser on figure’s ear as if phone Turns a metal box upside down and Holds a ribbon, coughs, and says
says “hiss.” and says “Hello?” says “It’s my school.” “Spaghetti is hot!”
FPP Points hose at something as if spraying Moves fire truck forward saying “wee Lays figures together and says Slides a figure on road downward.
water and says “splash.” woo.” “They’re holding hands.”

Note. FPP = functional play with pretense; OS = object substitution; IAO = imagining absent objects; AAA = assigning absent attributes.

5
6 Topics in Early Childhood Special Education 00(0)
Reliability and Procedural Fidelity
All sessions were video-recorded. A graduate student in
applied behavior analysis and autism independently coded
30% of the sessions per toy set and condition across each
child. When calculating the interobserver reliability data
(IOA), the number of agreements divided by the number of
agreements and disagreements was multiplied by 100
(Tekin-Iftar & Kırcaali-Iftar, 2013). The mean IOA was
100% for all full probe, maintenance, and generalization
sessions, and 96% (94%–100%) for the intervention.
Average IOA was 99.2% (96%–100%) across sessions and
children. We calculated procedural fidelity with the follow-
ing quotient: the number of observed experimenter behav-
iors divided by the number of preplanned experimenter
behaviors was multiplied by 100 (Tekin-Iftar & Kırcaali-
Iftar, 2013). Procedural fidelity was 100% for all full probe
and maintenance sessions, and 97.2% (95%–96.6%) for
intervention. Procedural fidelity was 85.4% (81.25%–
97.5%) for generalization sessions. The average procedural
fidelity was 96.5% (85.4%–100%) across conditions and
children.
Social Validity
The participating children’s mothers and teachers com-
pleted a questionnaire rating the intervention effectiveness.
The questionnaire for the mothers included the following:
(a) What are your opinions on pretend play skills taught to
your children? (b) To what extent do you agree that the
intervention increased the frequency of the child’s pretend
play? (c) To what extent do you agree with the statement
that the intervention increased the diversity (FPP, OS, IAO,
and AAA) of the child’s pretend play? (d) What could you
say about whether and how the child played pretend play
with other people and/or across different settings? (e) What
are the positive and negative aspects of the study? The
teachers were asked these questions and also the following
questions: Do you think that LTM is useful for increasing
the frequency and diversity of pretend play of children with
ASD? Will you use this method in one-to-one and/or group
training of children with ASD?
Results
Frequency of Pretend Play Behaviors and
Vocalizations
The frequency of each child’s pretend play behaviors and
vocalizations for each toy set is presented in Figures 1 to 6.
The frequency of each child’s pretend play behaviors in all
pre-intervention probe sessions was relatively low, reached
the mastery criterion during intervention, and maintained
when the intervention was removed. The total number of
prompts made by the implementer during intervention con-
ditions across toy sets is presented in the online supplemen-
tal Table S5.
During the initial probe condition, Bora exhibited two or
fewer pretend play behaviors or vocalizations for each toy
set. During intervention for PHS, his use of pretend play
behaviors and vocalizations increased in level and variabil-
ity. His pretend play behaviors and vocalizations increased
with the introduction of the intervention for FTS, followed
by a gradual increase for the last three sessions. This pattern
was replicated for the other toy set, FSS.
Can engaged in fewer than four pretend play behaviors
or vocalizations during the initial probe condition for each
toy set. With the introduction of the intervention for PHS,
the frequency of his pretend play behaviors and vocaliza-
tions abruptly increased, followed by a slight variability in
the last three sessions. His pretend play behaviors and
vocalizations showed a large increase in frequency with the
introduction of the intervention for FTS, followed by a
slight decrease in the last two sessions. During the third
probe condition, frequency of behaviors for FSS remained
at a high but slightly lower level than the previous three
intervention sessions. The frequency of Can’s pretend play
behaviors and vocalizations displayed an immediate and
large increase in level with the introduction of intervention
for FSS. During the initial probe condition, Deniz engaged
in four or fewer pretend play behaviors or vocalizations for
each toy set. With the intervention for PHS, there was an
immediate upward trend in the frequency of pretend play
behaviors and vocalizations. During the intervention for
FTS, an increasing trend in pretend play behaviors and
vocalizations was evident, followed by some increased
variability. During intervention for FSS, frequency of
Deniz’s pretend play behaviors and vocalizations continued
in an increasing trend with no overlap with baseline data.
During maintenance condition for PHS, Bora’s pretend
play behaviors and vocalizations showed an increasing
trend and remained at a level slightly higher than the inter-
vention condition. For FTS, there was a slight increase in
his pretend play behaviors, and no trend in his vocaliza-
tions, with a slight increase in level compared with the
intervention condition. For FSS, the data were stable
around the mastery criteria with a slight decreasing trend.
For Can, maintenance data indicated that there was an
increase in level and increasing trend of pretend play
behaviors and vocalizations for PHS and FSS. For FTS, his
vocalizations increased in level despite a slight decrease in
pretend play behaviors that still remained higher than in
intervention condition. Frequency of Deniz’s pretend play
behaviors and vocalizations showed a slightly increasing
trend with PHS. For FTS, the data showed an upward trend
and demonstrated a clear change in level across the three
maintenance sessions compared with the previous condi-
tions. Maintenance sessions for FSS showed a slight
Saral and Ulke-Kurkcuoglu
decreasing trend in his pretend play behaviors, and little
variability in his vocalizations, but still remained greater
than the intervention mean. Only Deniz exhibited two or
fewer pretend play behaviors or vocalizations during pre-
test generalization sessions. All children demonstrated
high levels of pretend play behaviors and vocalizations
during generalization sessions. In addition, their levels of
target behaviors exceeded the levels observed during the
intervention conditions.
Novel Pretend Play Behaviors and Vocalizations
Novelty was analyzed separately for both pretend play
behaviors and vocalizations. The mean number of novel
pretend play behaviors and vocalizations was considerably
low during all pre-intervention probe sessions and increased
during the instructional sessions; all children maintained
exhibiting novel behaviors. Mean and ranges of the novel
pretend play behaviors and vocalizations are presented in
the online supplemental Table S4. The examples of the
children’s novel pretend play behaviors and vocalizations
are presented in Table 2. The mean number of novel pre-
tend play behaviors and vocalizations for all children with
all toy sets increased with the introduction of the interven-
tion. The children also had more novel pretend play behav-
iors and vocalizations with PHS than with FSS and FTS,
respectively.
The online supplemental Table S4 shows that all novel
pretend play behaviors were maintained by all the children
with all toy sets. All children maintained exhibiting novel
pretend play behaviors and vocalizations at a higher level
than in intervention and baseline conditions. However, the
mean number of novel pretend play behaviors and vocaliza-
tions for Can and Deniz on FTS and FSS in maintenance
was lower than in intervention sessions but still higher than
in baseline. During generalization, all children engaged in
similar or higher numbers of novel pretend play behaviors
and vocalizations with PHS and FTS than in intervention
conditions. However, they engaged in similar-to-baseline
levels with FSS.
Sequences of Pretend Play Behaviors
None of the children demonstrated more than two sequences
of pretend play during baseline or probe conditions prior to
intervention. Across subsequent conditions, the number and
length of play sequences increased for all children. In the
final probe condition, Bora exhibited two to 16 pretend play
behaviors across the 33 sequences while Can displayed two
to 17 behaviors across 31 with all toy sets. However, the
number of play sequences for Deniz was slightly lower. He
demonstrated two to 18 pretend play behaviors across 26
play sequences.
7
Diversity of Pretend Play Behaviors
Children’s different pretend play behaviors and their cate-
gorical diversity are presented in Figures 1 to 3 and Table 3,
respectively. The diversity of children’s pretend play behav-
iors was low during the pre-intervention probe sessions and
during the intervention all children had an upward trend,
which maintained during the post-intervention sessions.
All the children exhibited few different pretend play
behaviors and vocalizations during baseline/probe sessions.
The criteria determined for all children were 15 different
pretend play behaviors and 10 different vocalizations for
each toy set. All the children met and maintained these cri-
teria across toy sets. The children primarily exhibited
behaviors in the FPP and OS categories during the initial
probe conditions. During intervention, all children showed
large increases in frequency of pretend play behaviors in all
categories with each toy set (see Table 3).
Bora exhibited higher numbers of behaviors in FPP with
PHS than the other three categories, similar numbers of FPP
and OS behaviors with FTS, and similar numbers of FPP
and AAA with FSS. Can displayed more FPP pretend play
behaviors with both PHS and FSS than the other pretend
play categories and more AAA behaviors with FTS. Deniz
exhibited more FPP behaviors with PHS and FTS, and AAA
behaviors with FSS.
Categorical Diversity of Novel Pretend Play
Behaviors
All the children exhibited novel pretend play behaviors dur-
ing the intervention in each category, except Bora in the OS
with the FSS. Bora and Can exhibited novel pretend play
behaviors mostly in FPP and OS, whereas Deniz exhibited
novel pretend play behaviors in the FPP and AAA catego-
ries in total (see the online supplemental Table S6).
Social Validity
All mothers and teachers agreed on the importance of teach-
ing pretend play skills for their children. One mother stated
that she had not considered play skills as significant previ-
ously, but that she realized its significance for her child after
the study. The mothers and teachers stated that their chil-
dren exhibited more pretend play behaviors after the study.
One mother stated that functional vocalizations exhibited
by her child increased during the play; he invited his sister
to play and they exhibited reciprocal pretend play behavior.
One teacher reported that the child who did not interact with
toys during free play time started to exhibit pretend play
behaviors with his friends during the class. All mothers and
teachers reported an increase in the children’s pretend play
behaviors across different categories. For example, the
8 Topics in Early Childhood Special Education 00(0)

Figure 1. Frequency and diversity of pretend play behaviors for Bora.

Saral and Ulke-Kurkcuoglu 9

Figure 2. Frequency and diversity of vocalizations for Bora.

10 Topics in Early Childhood Special Education 00(0)

Figure 3. Frequency and diversity of pretend play behaviors for Can.

Saral and Ulke-Kurkcuoglu 11

Figure 4. Frequency and diversity of vocalizations for Can.

12 Topics in Early Childhood Special Education 00(0)

Figure 5. Frequency and diversity of pretend play behaviors for Deniz.

Saral and Ulke-Kurkcuoglu 13

Figure 6. Frequency and diversity of vocalizations for Deniz.

14 Topics in Early Childhood Special Education 00(0)

Table 3. The Number of Unprompted Pretend Play Behaviors Exhibited by the Child, Toy Set, and Pretend Play Category During
Baseline and Intervention Conditions.

Bora Can Deniz

Participant Category Category Category

Toy set Condition FPP OS IAO AAA FPP OS IAO AAA FPP OS IAO AAA
PHS Probe I 0 2 0 0 8 0 0 0 3 5 0 0
Intervention 35 30 12 18 32 21 22 14 38 36 22 29
FTS Probe I 3 0 0 0 3 0 0 0 3 0 2 0
Intervention 21 22 13 12 38 41 30 44 55 36 39 28
FSS Probe I 5 0 0 0 8 0 0 0 4 0 0 0
Intervention 21 14 16 22 30 22 19 21 40 23 29 45

Note. PHS = playhouse toy set; FTS = farm toy set; FSS = fire station toy set; FPP = functional play with pretense; OS = object substitution; IAO =
imagining absent objects; AAA = assigning absent attributes.

children started to exhibit novel pretend play behaviors,
such as using a jar as a musical instrument, moving hands
up and down as if putting sugar in a cup, and touching a toy
oven and saying, “Ouch, it’s hot.” Furthermore, according
to the mothers’ and teachers’ responses, the children dis-
played pretend play behaviors with peers across different
settings such as different rooms at school. Two mothers
indicated that their children started to enjoy the play, their
play was not limited to only one toy, and that they diversi-
fied their play behaviors. All teachers considered LTM as an
effective method and stated that they would implement
LTM in classes as it would prevent prompt dependency.
One teacher indicated that a significant increase was
observed in the duration of play of his student. The other
teachers reported that the children stopped wandering in the
class and started to engage in pretend play more. No moth-
ers or teachers reported any negative aspects of the study.
Discussion
We observed increases in the frequency and diversity of
pretend play behaviors and vocalizations of three children
with ASD when using LTM with CI. In addition, novel
pretend play behaviors, novel vocalizations, and sequences
increased, maintained, and generalized across different
conditions.
children will respond to environmental stimuli without
adult prompts and avoid prompt dependency. In addition,
the adult does not interrupt the play interaction during LTM,
which supports positive social interaction. This also allows
the child to respond independently and might motivate the
child to produce more spontaneous, unprompted, and novel
play behaviors.
Contingent Imitation
Increases in the frequency of unprompted pretend play
behaviors are consistent with the results of other studies in
which all categories of pretend play were taught to children
with ASD through LTM (Kasari et al., 2006). Of these
studies, only four used CI with LTM (Barton, 2015; Barton
et al., 2013; Barton & Wolery, 2010; Kasari et al., 2006).
Kasari et al. (2006) reported that the child’s mother used CI
for 5 to 8 min in the floor sessions to teach pretend play.
Other researchers reported the use of CI throughout the
entire session at a 12- to 20-s interval and across conditions
(Barton, 2015; Barton et al., 2013; Barton & Wolery, 2010).
In the current study, the implementer also used CI across all
conditions. During the probe sessions, the implementer
refrained from giving prompts throughout the 5-min play
sessions and used CI only. Thus, research supports using CI
with LTM to increase pretend play.

LTM and Play Pretend Play Behaviors and Vocalizations

The current study supports the previous research showing
the effectiveness of LTM on teaching pretend play skills for
children with ASD (Barton, 2015). LTM can be particularly
effective for teaching these skills for a number of reasons.
First, the prompts can be selected based on the child’s learn-
ing history, embedded into play contexts, and the adult can
easily fade these prompts by starting with the natural prompt
based on the child’s response. This is essential so that the
The children exhibited novel pretend play behaviors across
all intervention and post-intervention probe sessions, except
Bora and Can in a few intervention sessions with the FSS.
However, all the children exhibited fewer novel pretend
play behaviors and vocalizations with the FSS than with the
other toy sets. Knowing the features and functions of a toy
or an object may increase the probability of demonstrating
more play behaviors related to it (Hidi et al., 2004). Thus,
Saral and Ulke-Kurkcuoglu
the PHS and FTS could have been more practicable for situ-
ations and behaviors the children encountered and acquired
in real-life contexts. More research is needed to assess
novel pretend play behaviors and vocalizations in children
with ASD. Furthermore, the children exhibited the highest
number of novel pretend play behaviors in the FPP, AAA,
IAO, and OS, respectively. Considering that only three
potentially symbolic objects were included in each toy set,
future studies may investigate the effects of using more
symbolic objects on the distribution of novel pretend play
behaviors by categories. Finally, these findings are signifi-
cant for developing and expanding the literature in terms of
novel pretend play behaviors.
In the study, vocalizations/verbal prompts were embed-
ded into a model prompt at the second and last prompt
level. All the children exhibited vocalizations during the
intervention, except Bora with the FTS in a session.
Furthermore, they maintained exhibiting a higher number
of vocalizations across all post-intervention conditions.
Vocalizations, which are a characteristic of pretend play,
have great importance for providing clear evidence for the
inference of pretense, defining pretend play behaviors,
ensuring the continuation of play, and enabling the child to
assign roles (Barton & Wolery, 2008). However, studies
measuring children’s vocalizations are still limited (Kasari
et al., 2006). Second, no studies that aimed to teach four
categories of pretend play through LTM measured chil-
dren’s novel vocalizations. In this study, all the children
exhibited novel vocalizations during the post-intervention
probe sessions, except Bora with the FTS and Deniz with
the FSS in a few sessions. However, all the children dis-
played fewer novel vocalizations with the FSS than with
the other toy sets. The low number of novel pretend play
behaviors exhibited with the FSS may have prevented the
number of novel vocalizations.
Different Pretend Play Behaviors and
Vocalizations
In the present study, when the child attempted to exhibit the
same behavior for the fourth time within a session, the
implementer interrupted his attempt and prompted another
pretend play behavior immediately, which likely contrib-
uted to the increases in the diversity of behaviors/vocaliza-
tions. The diversity of pretend play behaviors remained at a
high level across all post-intervention probe conditions.
This support previous research in that children use diverse
play behaviors when they are specifically taught (Barton,
2015; Barton et al., 2019; Barton & Wolery, 2010; Kasari et
al., 2006). For example, Barton and colleagues (2019)
found that diversity of play increased only when specifi-
cally reinforced as compared with conditions when all play
behaviors were reinforced for a child with ASD. The
15
diversity of pretend play behaviors and vocalizations may
have great importance as it enables a child to initiate and
maintain play activities. Additional research aimed at
increasing the diversity of pretend play in children with
ASD should be conducted.
Categorical Diversity of Pretend Play Behaviors
and Vocalizations
The children exhibited primarily FPP and OS behaviors
during baseline and full probe conditions, and increased
their use of behaviors from other categories after interven-
tion. This aligns with research on the emergence of pretend
play in children (Belsky & Most, 1981) and supports
sequence of pretend play proposed by Barton (2010). In this
study, the implementer targeted increasing the categorical
diversity of pretend play behaviors by prompting behaviors
in each category. Thus, the number of children’s pretend
play behaviors increased in diversity and remained at high
levels during intervention conditions. Bora and Can exhib-
ited pretend play behaviors in FPP and OS, whereas Deniz
displayed more FPP and IAO behaviors. Barton (2015)
specifically taught FPP behaviors before more complex
pretend play behaviors (i.e., OS, IAO, and AAA). They
reported that the children demonstrated more FPP behaviors
even when teaching other categories of pretend play, which
aligns with our results. In the future, researchers should
examine the effects of teaching FPP and then shifting to
other categories.
Sequences of Pretend Play Behaviors
Considering that pretend play behaviors of children with
ASD are often discrete and repetitive, it might be particu-
larly important to teach them to engage in sequences of pre-
tend play behaviors. However, previous research has shown
that sequences rarely emerge except when explicitly taught.
For example, Barton (2015) prompted two participants to
specifically exhibit sequences, which increased play
sequences. Barton et al. (2019) also found that a child with
ASD’s sequences increased when specifically targeted.
Similarly, we prompted the sequences of behaviors system-
atically. Thus, the number and length of sequences increased
during the intervention and subsequent conditions. Future
studies may focus on examining the effects of a longer
response interval (e.g., 8 s) on the number and length of
sequences.
Maintenance and Generalization
All the children maintained exhibiting vocalizations and
behaviors, and displayed novel pretend play behaviors. Only
three studies, aiming to teach four categories of pretend play
16
through LTM, measured maintenance of pretend play behav-
iors and vocalizations (Barton, 2015; Barton & Wolery,
2010; Ulke-Kurkcuoglu, 2015), and reported positive out-
comes. Two of these studies collected maintenance data
(Barton, 2015; Barton & Wolery, 2010). However, no stud-
ies collected data on novelty of pretend play behaviors.
Additional replications with a focus on maintenance of
novel behaviors are needed.
All the children generalized pretend play behaviors
across different conditions and exhibited novel pretend play
behaviors and vocalizations during the generalization ses-
sions mostly with the PHS and FTS. Barton and Wolery
(2010) measured generalization across adults and toy sets.
The findings showed pretend play behaviors and vocaliza-
tions were lower in frequency during generalization. Barton
(2015) measured generalization during a typical free play
routine, but reported that no children reached intervention
levels during these generalization sessions. Furthermore, to
our knowledge, no studies measured generalization of novel
pretend play behaviors and vocalizations. In this study, chil-
dren generalized the target skills across similar toys, their
home as a natural setting, and their mothers. The interven-
tion provided the children with opportunities for social
interactions. Future research might conduct generalization
sessions in natural settings and with family members and
peers.
In this study, the children exhibited more behaviors in
four categories during the generalization and the last probe
than during the intervention, which extends the previous
research. For example, Kasari et al. (2006) found that the
overall play level of children with ASD with a mental age of
24 months after the intervention was FPP, although they
exhibited pretend play behaviors in the OS, IAO, and AAA
categories during the intervention. The children’s develop-
mental level may have contributed to the acquisition, main-
tenance, and generalization of the target skills. However,
children with ASD might require clear and systematic
instruction to acquire more complex play skills (Barton et
al., 2019), which is demonstrated in this study.
Finally, in this study, the implementer verbally explained
to the mothers how they would proceed along the steps and
asked them to conduct a session with a nonparticipant child
and give feedback accordingly. All mothers were persistent
in prompting and directing the child to a target behavior; the
implementer asked them to refrain from contingent vocal
imitation during the sessions, which might have been atypi-
cal for them. During many of the generalization sessions,
the mothers did not present the skill direction to their chil-
dren. Procedural fidelity during the generalization sessions
averaged 85.4% (range = 81.25%–97.5%). Additional
research focused on training parents to teach their children
more complex play skills is needed.
Topics in Early Childhood Special Education 00(0)
Social Validity
Few studies investigated the social validity of teaching pre-
tend play skills. The opinions of teachers (Barton et al.,
2013), mothers, and graduate students (Ulke-Kurkcuoglu,
2015) have been examined. Researchers in both studies
reported raters providing positive opinions, which is consis-
tent with the findings of our study. In this study, the chil-
dren’s mothers and teachers indicated that the children
started to invite their siblings and peers to play, exhibited
novel pretend play behaviors, displayed fewer challenging
behaviors, and the duration of children’s play increased. In
future studies, social validity data may be collected from
children themselves, other family members such as sib-
lings, or stakeholders who are less likely to be biased such
as parents of children with ASD who are not participating in
the study.
Limitations
All the sessions, except the generalization, were conducted
in a semi-structured setting located in the institution where
the children attended by a researcher who was not endoge-
nous to the setting, which limits the ecological validity of
the research. Second, there is evidence that all children gen-
eralized a few behaviors in FTS across the symbolic objects
in FSS. This resulted in a slightly increasing trend at Probe
III with FSS, which limits conclusions about functional
relations. Third, the second observer was not blind to the
study conditions. This might have introduced measurement
bias. Finally, although we measured generalization across
materials, the toy sets were very similar to the intervention
toys. Future studies should use novel toy sets for facilitating
generalization.
Conclusion
The study showed that LTM use with CI and verbal map-
ping was effective in increasing the frequency and diver-
sity of children’s pretend play behaviors. The pretend play
taxonomy proposed by Barton (2010) was used for the
definition and categories of pretend play. Future research
may use this emerging taxonomy to teach, define, and
assess pretend play.
Authors’ Note
This article is based on the first author’s MA thesis.
Acknowledgments
We thank our participants and their families for their participation
and collaboration, Anadolu University for supporting the research,
and Elif Tuncel for collecting reliability data.
Saral and Ulke-Kurkcuoglu
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This research was funded by Anadolu University Committee of
Scientific Research Projects (Project No. 1610E634). The views
expressed in this article do not necessarily reflect those of Anadolu
University Committee of Scientific Research Projects.
ORCID iD
Burcu Ulke-Kurkcuoglu https://orcid.org/0000-0003-0187-9742
Supplemental Material
Supplemental material for this article is available online.
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