Correlation Between the Theory of Mind and Pretend Play in 5 to 7-Year-Old Children with Autism and Their Typically Developed Peers

Background: Autism spectrum disorder (ASD) is a neurodevelopmental disorder with 2 main symptoms of social and communication deficits and stereotyped behaviors. Pretend play and theory of mind (ToM) have an essential role in a child’s cognitive and social development. Objectives: In this study, different variables of pretend play with levels of ToM were examined in 2 groups of typical children and children with autism. Methods: In this case-control observational study, 45 typical children and 18 children with autism aged 5 to 7 years participated. For both groups, the ToM test was performed to measure the levels of ToM, and the child-initiated pretend play assessment (ChIPPA) was performed to analyze the pretend plays in both groups. Both tests were performed directly on children, and the scores were recorded by the examiner. Results: The results showed a significant positive relationship between the total score of ToM and pretend play. In children with autism, there was no difference between the ToM scores regarding age (P > 0.05). There was also a significant relationship between the levels of ToM, percentage of elaborate pretend actions (PEPA), and the number of object substitutions (NOS; P < 0.001). The scores of the ToM and pretend play levels of children with autism and typical children were significantly different (P < 0.001). Conclusions: Based on the findings, the ToM and pretend play levels were lower in ASD children than in typical children. In addition, children who had higher PEPA scores and better NOS had higher ToM scores.