This case study refers to R., a 4-year-old boy diagnosed with autism, with a high level of receptive language, with an extensive naming repertoire (he can name objects, actions, adjectives, prepositions, adverbs, but also pronouns or emotions), who can imitate physical or object movements, ask for desired activities and also know how to answer some personal questions (What’s your name?

How old are you? What are your parents’ names?). R. usually speaks in sentences of 3-4 words and prefers to play with vehicles, kitchen objects or pretend he is a doctor.


In his most favorite games, R. does only a few actions spontaneously. For example, in the vehicle game, the actions he normally does are: drives the cars around, puts them in their parking spots, takes them to the car wash where he washes them, then takes them to the gas station where he fills up with gas. In the kitchen game,

R. cuts the vegetables with a knife, mixes them in a bowl, then takes them out on a plate and pretends to be burnt, and finally feeds a character. When he chooses the doctor game, the only actions shown are: consult the dolls, give them cough syrup, give them an injection and then bandage them. In addition to the fact that R. has just a few ideas of actions in play, he tends to repeat certain favorite actions over and over again, without further contact with the adult.

For example, it can take minutes around the time he puts gas in the car, or the time he stirs the vegetables in the pan. He always accompanies these recurring movements with high-pitched sounds that match the action being taken. Also, in the doctor game, he creates opportunities to give syrup to patients again and again. With these things in mind, our goal was to increase the number of actions in the game so that R. would vary what he does and increase the length of his independent play.


For this objective we used the hierarchy of prompts from Project ImPACT. We applied the method to R.’s three favorite play sets: vehicles set, kitchen set, doctor set. Next, we will then extend the procedure to other sets of toys. According to ImPACT, the prompts we can use to increase the number of actions a child does with their favorite toys are multiple, from the least intrusive to the most intrusive. Here they are:

  1. Make a leading comment. Make a comment that cues the child what to do next or how you would like to get involved. Pair it with a gesture to help your child respond.
  2. Ask a question. Ask the child a question to cue him to do something new with the toy. The child should respond to your question by showing you the answer.
  3. Give choices. Give the child a choice of two new ways to play with the toy, to help him expand his play.
  4. Use a verbal instruction. Tell the child what else to do with the toy he is playing with.
  5. Model an action for the child to imitate. Model a new action for your child to imitate.
  6. Use physical guidance. Physically guide your child to imitate the play action of following the verbal instruction.

In conclusion, the least intrusive prompt we can give the child using this method is to make a suggestive comment on his actions. And the most intrusive way to help your child develop his play involves using the physical prompt to do an action.

In working with R., we decided to start using the least intrusive prompt, that is, we choosed to comment suggestively when we noticed that R. is no longer doing new game actions or repeating the same ones over and over again. If we noticed that this help was not enough, we turned to the next prompt on the list, that is, we asked what he could do next. If this second prompt didn’t seem to work either, we used the next type of help on the list and so on.

Play training sessions took place daily, twice a day. Each session lasted 30 minutes. We applied the procedure for 3 weeks. During this time, the child practiced with two therapists. The child and the adult were seated facing each other with the toys in the middle. For the vehicle set we used the following toys: cars, parking spaces, tools, gas stations, characters, road pieces, lego pieces, cleaning foam, sponges, character boxes. For the kitchen set, the toys used were: tableware, cutlery, stove, oven, mixer, coffee maker, tea set, coffee set, food, pizza, sauces and spices, characters, chairs, tables, towels, cakes, candles, sink for washing dishes, sponges and detergents. At the doctor’s set, we brought characters, stethoscopes, syringes, plasters, medicines, thermometers, recipes, slices of toast, teapot, cups of tea, honey or sugar, and milk. Before starting the procedure, we made sure that we had the toys in duplicate so that both the adult and the child could use them at the same time, and the adult could provide a play model if necessary. We also put the toys close to the child so that he can be inspired to do new actions, even without our suggestions.

For each set, R. was left to start the game alone. As long as R. performed appropriate play actions, independently, the adult imitated him and let him lead the game further with his ideas. But if R. stopped doing any more actions, if he repeated the same movement over and over again, the adult intervened with the prompt level we established. 

For example, if R. exhausted all the moves he knew in the vehicle game, if even the presence of toys did not help him come up with new ideas, then the adult offered a suggestive comment (It seems that the car has enough gas now!, I think the car it’s ready to go now!, I think he just made a wedge!). The adult did the same if R. repeated a game action too much. For example, when cutting vegetables again and again, the adult would make comments again (I think all the vegetables are cut!, I think there are enough to eat!, Now we have finished cutting the vegetables!). If these suggestions were not enough to get R. to do a new play action with the present toys, then the adult asked a helping question (The vegetables are cut now. What do we do next?, The car is ready to go. Where are we going?, The puppies got into the car. Where?, The baby has had enough cough syrup. What’s next?).

After each prompt and correct response of, the adult again allowed the child to continue playing as he wished to as long as he varied the actions and did not repeat a movement over and over again.

Results and discussion

The number of play actions made by R. increased following this procedure. For the vehicle set, R. grew from 4 to 10 play actions. R. learned to repair the car, build roads, stop the car at a stoplight, drive characters, build bridges and make barriers. For the kitchen set, R. additionally learned to season the food, feed the characters, wash the dishes, wipe the dishes, prepare tea after the meal, feed the characters with dessert. In the doctor’s set, R. could also give pills to patients, prepare them tea, write prescriptions for them.

From time to time R. still repeated a favorite play actions several times and needed the adult to prompt him by suggestive comment to change the action. R. also transferred the new play actions at home when playing with his family and with similar but different toys. R. needed intensive training for four more sets of toys, so that he could then more easily generate new game ideas, without the prompting of the adult, using only the materials provided.