Autism is a disorder characterized by alterations present since the age of three and by qualitative impairments in communication and social interaction and by the presence of restricted patterns of interest and behavior. ASDs can be conceptualized as a spectrum disorder with hierarchical levels of severity, as described in DSM-5 (American Psychiatric Association, 2013). In 2010, there were an estimated 52 million cases of ASDs, which means a prevalence of 7.6 per 1000 or one in 132 persons (Baxter, Brugha, Erskine, & Scheurer, 2015). Considering its prevalence and the large scope of affected areas, autism is one of the most disabling developmental disorders (Mehta, Gandal, & Siegel, 2011; Varanda, 2011). The impairments in communication, social interaction, and the use of imagination can be explained through different theories.
One of the theories that explain autism states that executive functions related to planning, working memory, impulse control, inhibition, and mental flexibility are typically impaired in people with neurodevelopmental disorders involving frontal lobe deficits. Such clinical disorders include attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, Tourette’s syndrome, phenylketonuria, and schizophrenia (Hill, 2004). According to this theory called as executive dysfunction theory, the difficulties in communication and social interaction and, mainly, the restricted patterns of interests and behavior could be explained by inadequate ability for planning, deficient working memory abilities, lack of control and impulse inhibition, and insufficient mental flexibility (Ozonoff, Pennington, & Rogers, 1991; Lopez, Lincoln, Ozonoff, & Lai, 2005).
For the complex characterization of the executive functions, it is necessary to describe its hierarchical structure with the characterizations of its subfunctions (Zelazo & Müller, 2002). Concerning the implication of hierarchical structure of executive functions in performing a task, it is possible to describe different phases along its performance as it happens when attempting to solve a problem during Wisconsin Card Sorting Test (Cunha, Trentini, Argimon, Oliveira, Werlang et al., 2005). At first, there is an intention, after the detection of a pattern, or an elaboration of the representation of the problem to be solved as well as a plan to solve it. After that, it is necessary that such a plan is kept in mind during sufficient time in order to guide the thought action. The action is executed, and the mistakes are then evaluated for a probable correction. The inflexibility that negatively interferes with the execution and success of the action can occur at any described phase. In the specific situation of Wisconsin Card Sorting Test (Cunha et al., 2005), the inflexibility may take place when a change in the sorting rule occurs and the subject perseveres in the previous rule because a new plan was not formed or was formed but was not executed. The executive function analysis based on this model allows the detection of where there is a break in the process of problem solving. Executive functions can be understood through a problem-solving framework.
Flexible cognition or cognitive flexibility “entails the dynamic activation and modification of cognitive processes in response to changing task demands” (Déak, 2003, p. 275). When demands and task context change, the cognitive system can adapt, shift attentional focus, select information to guide and choose necessary responses, form plans, and generate new activation to feed back into the system. If those processes result in well-adapted representations and actions, it is possible to state that those processes succeeded due to flexible cognition or cognitive flexibility.
Cognitive flexibility is involved in systems of actions including the use of tools, social interaction, spatial navigation, planning, and creative thinking. Besides all those, cognitive flexibility has a fundamental role in the development and well-succeeded use of language, once for acquiring language, one has to have a rich representational system at hand as well as flexible means to decide among the linguistic representations available (Déak, 2003).
The behavior of people with autism that could be explained by the executive dysfunction theory includes the need for routine, strong preference for repetitive behavior, lack of impulse control, difficulty in initiating new actions, and difficulty of shifting from one task to another (Hill, 2004; Hill & Frith, 2003; Hughes, Russell, & Robbins, 1994). However, Rajendran and Mitchell (2007) cite some authors who, after having evaluated individuals with autism and individuals with attention-deficit hyperactivity disorder and Tourette’s syndrome, concluded that individuals with autism presented a specific deficit in cognitive flexibility, while inhibitory control, for instance, seems to be less affected than in other disorders. Although deficits in executive functions can be present in various clinical disorders, individuals with autism has shown significant deficits in EF domains, especially in planning and cognitive flexibility, when compared to individuals with attention-deficit hyperactivity disorder, for instance (Geurst, Verté, Oosterlaan, Roeyers, & Sergeant, 2004). In fact, difficulties in cognitive flexibility in autism are related to deficits in the theory of mind, communication skills, and maladaptive behaviors (Memari, Ziaee, Shayestehfar, Ghanouni, Mansournia et al., 2013) which are associated with quality of life (de Vries & Geurts, 2015).
Varanda (2011) did a research to assess ten subjects diagnosed with autism in syntactic awareness, central coherence, non-verbal intelligence, social and communicative development, and patterns of behavior and interests to verify the probable relationship among these variables and to detect probable linguistic profiles related to syntactic awareness. In a first study, it was verified that some abilities such as self-monitoring and self-regulation should be developed or refined in order to allow a better performance in syntactic tasks. Syntactic awareness is a metalinguistic task and requires resources from the central executive system such as self-monitoring as self-regulation to be accomplished successfully. When assessing profiles of communication and social interactions, Varanda (2011) ascertained the presence of failure in social interaction attempts and social response adequacy, indicating a probable primary deficit, which is joint attention deficit. Joint attention refers to social cognition and a variety of behaviors such as following attention (imitation, social reference) and drawing attention such as pointing, language, protodeclarative, and protoimperative gestures (Stahl & Pry, 2004). Difficulties in the fast shifting of attentional focus can contribute to an increase in joint attention failure. According to Stahl and Pry (2004), the need for attention in these abilities seem to be part of a triad, demanding flexible transition between attention to oneself, to some object or event, and to someone else. Therefore, cognitive flexibility would be directly related to failure in joint attention. These two studies had the aim to test the previous hypothesis that there would be a relationship between syntactic awareness and central coherence, non-verbal intelligence, social and communicative development, as well as development of behaviors and interests and to test the hypothesis that there would be varied linguistic profiles concerning syntax among subjects with autism. However, only in her third study (Varanda, 2011) that was based on analyses made on case reports, relying on information given by the parents of the individuals with autism in an interview, it was possible to formulate a hypothesis instead of corroborating hypotheses previously thought as in the other two studies. The two studies developed in laboratory testing the subjects under controlled conditions together with the complementary findings of the third study offered high ecological validity. Therefore, based on the reports provided by the parents of the individuals with autism, it was possible to infer that cognitive flexibility or the lack of it is present in all the difficulties showed by the subjects not only in communication but also in social interaction and behavioral patterns. According to this idea, cognitive flexibility cannot be understood as an isolated ability but as a unified account which can be considered a property of the cognitive system. Cognitive flexibility requires the interaction of several mechanisms (e.g., attention shifting, conflict monitoring, and perception) that respond to specific environmental demands (such as rule changes) in order to achieve flexible behavior (such as solving a problem in a new way) (Ionescu, 2012). Children with autism show developmental core deficits in joint attention which is a prelinguistic communicative ability and also in play (Kasari, Chang, & Patterson, 2013). Playing in autism is characterized by reduced frequency, complexity, novelty, and spontaneity (Kasari, Huynh, & Gulsrud, 2011). In fact, playing becomes an important focus of intervention in autism once developmental indicators of difficulties in autism are a relative absence of creativity and fantasy in the processes of thought relating strongly with social, cognitive, symbolic, and linguistic development. Playing favors abstractions, generalizations, and transitions of meanings (Amato et al., 2014). When considering cognitive flexibility as a property of the cognitive system requiring the interaction of attention shifting, conflict monitoring, and perception, it is possible to argue that sameness in play showed by individuals with autism is related to the lack of cognitive flexibility. However and although play is considered an important part of development and deficits in playing can be detected among children with autism, those children lack play experiences with others decreasing their exposure and development in social play (Kasari et al., 2013).
Regarding therapeutical efforts to improve cognitive flexibility among individuals with autism, the effects of direct EF interventions in ASD have presented mixed results, either positive or null (de Vries, Prins, Schmand, & Geurts, 2015). Nevertheless, once ASD has been lately understood as a disorder with a neurobiological explanation, the idea of remediating the core brain deficits involved in social and non-social cognitive dysfunction in ASD has been discussed (Eack, Bahorik, Hogarty, Greenwald, Litschge et al., 2013). Cognitive rehabilitation can vary largely (Eack et al., 2013), but cognitive flexibility which can be associated with multiple abilities can offer a promising alternative. When focusing on the improvement of cognitive flexibility among children with autism, researchers and therapists must consider not only the deficits related to autism but also the fact that the choice of strategies for improving flexible cognition must take the level of children’s development into account. Bergen (2016) compares two broad approaches for the minimization of ASD difficulties. One of them is based on the theory of behavioral modification, and the other one is based on the theory of human development which focuses on the promotion of typical play as a mediator of autistic behavior. The author mentions the proposal that emotional organization is a primary task of children and mentions the typical stages of such emotional organization, mentioning the recommendation of Greenspan (as cited in Bergen, 2016). The mentioned developmental stages can be stimulated through an approach based on playing called Floortime. Bergen (2016) stated this method is similar to guided play in which there is the involvement of adults and children in complementary interactions in playful activities. Guided play is different from free play once incorporates adult-scaffolded learning objectives remaining child-directed (Weisberg, Hirsh-Pasek, & Golinkoff, 2013). Another issue concerning the focus of cognitive interventions is that it should have a comprehensive approach considering not only the cognitive deficits but also and mainly social-cognitive ones (Eack et al., 2013).
Cognitive flexibility has been pointed as an ability which allows people to be successful in swifting their attentional focus in complex tasks such as social interaction situations, for instance, and deficits in this ability can harm other abilities in autism as verified by Varanda (2011). Therefore, the suggestion of using play and games for the improvement of cognitive flexibility, planning ability, and flexible use of language among children and adolescents with autism can minimize the negative impact that the lack of behavioral repertoire presented by individuals with autism for accomplishing daily tasks at home and school. In fact, cognitive flexibility seems to be a core ability for the development of a satisfactory pattern of social interaction which allows these individuals to actively take part in life in society. Faja, Dawson, Sullivan, Meltzoff, and Estes et al. (2016) argue that executive dysfunction contributes to playing deficits in ASD. They state that early executive function skills may be critical in order for verbal children with autism to develop play.
This research aimed to assess the present developmental level of children and adolescents with autism in communication, social interaction, and patterns of behavior and interests, in non-verbal intelligence and cognitive flexibility. Besides, it proposed the use of playing activities and games for the development and enhancement of cognitive flexibility and planning. After intervention, gains in communication, social interaction, and patterns of behavior and interests and cognitive flexibility were checked.