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Australian Occupational Therapy
Journal
Australian Occupational Therapy Journal (2010) 57, 137–145
doi: 10.1111/j.1440-1630.2009.00821.x
Research Article
Comparison of the play of children with attention deficit
hyperactivity disorder by subtypes
Reinie Cordier,1 Anita Bundy,1 Clare Hocking2 and Stewart Einfeld1,3
1Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia, 2School of Rehabilitation and
Occupation Studies, AUT University, Auckland, New Zealand, and 3Brain and Mind Research Institute, The University
of Sydney, Sydney, New South Wales, Australia
Background: Studies have found differences in the nature
and severity of social problems experienced by children
with different subtypes of attention deficit hyperactivity
disorder (ADHD). Given that play is often the context for
acquiring social skills, there is surprisingly limited
research examining whether these differences distinguish
the play of children within the groups.
Methods: Using the Test of Playfulness (ToP), we examined the similarities and differences in play between children (aged 5–11 years) diagnosed with the three DSM-IV
ADHD subtypes: inattentive (I-subtype; n = 46), hyperactive-impulsive (HI-subtype; n = 28) and combined subtypes (C-subtype; n = 31).
Results and conclusions: Bias interaction, an item-byitem analysis, revealed that the hierarchy of ToP items
was similar for children with the HI- and C-subtypes, but
differed for children with the I-subtype. Specifically, children with the I-subtype found it more difficult to become
intensely engaged in play and to take on playful mischief
and clowning; however, they found social play items to be
easier. Conversely, whereas mischief and clowning were
relatively easier for children with the HI- and C-subtypes,
many items reflecting social interaction were more
difficult. These findings suggest that interventions can be
Reinie Cordier MOccTher; BSocSc Hons (Clin Psych).
Anita Bundy ScD, OTR, FAOTA; Chair of Occupation and
Leisure Sciences. Clare Hocking PhD, MHSc (OT); Associate Professor. Stewart Einfeld MD, DCH, FRANZCP; Chair
of Mental Health, Faculty of Health Sciences & Senior Scientist, Brain and Mind Research Institute.
Correspondence: Anita Bundy, Faculty of Health Sciences,
The University of Sydney, P.O. Box 170, Lidcombe, Sydney,
NSW 1825, Australia. Email: [email protected]
Accepted for publication 1 September 2009.
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tailored to these differing presentations. However, further
research is needed to confirm the findings.
KEY WORDS play, child development, paediatrics.
Introduction
Substantial research has shown differences between children representing the three attention deficit hyperactivity
disorder (ADHD) subtypes identified in the DSM-IV,
namely predominantly inattentive (I-subtype), predominantly hyperactive-impulsive (HI-subtype) and combined (C-subtype) (American Psychiatric Association,
2000; Barkley, 2003). Children with the subtypes are
reported to differ in their cognitive processes, psychosocial presentation, comorbid conditions and response to
treatment (Barkley; Diamond, 2005).
Although three subtypes have been distinguished,
there is mounting belief that the HI- and C-subtypes are
quite similar and that they differ substantially from the
I-subtype (Diamond, 2005; Milich, Balentein & Lynham,
2001). Children with the HI- and C-subtypes are more
likely to have the behaviours classically associated with
ADHD. They tend to be distractible, have poorer persistence and have problems with planning and shifting
between activities (i.e. transitioning).
In contrast, children with the I-subtype are less distractible and tend to be more withdrawn (Milich et al.,
2001). Also, children with the HI- or C-subtype tend to be
more aggressive and impulsive (Carlson, Shin & Booth,
1999; Gaub & Carlson, 1997) and have greater externalising behaviours (Baeyens, Roeyers & Vande Walle, 2006;
Carlson et al.), whereas children with the I-subtype tend
to be socially passive (Barkley, 2003) and present with
more internalising behaviours (Baeyens et al.; Carlson
et al.). Unlike children with HI- or C-subtype, children
with the I-subtype seem to lack motivation (Diamond,
2005). Perhaps unsurprisingly, children with the I-subtype are less likely than the others to develop oppositional defiant disorder (ODD) and conduct disorder (CD)
(Baeyens et al.).
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R. CORDIER ET AL.
Given the well-documented differences among children with the varying ADHD subtypes, it is reasonable to
suspect that their play patterns also will differ. However,
there is surprisingly little published research on the
impact of ADHD on play. The limited existing research
on play and ADHD in general suggests that children with
ADHD engage in less associative and cooperative play
than typically developing peers (Alessandri, 1992). Leipold and Bundy (2000) found that children with ADHD
are less playful. Alessandri found that children with
ADHD struggle to transition between play activities. Melnick and Hinshaw (1996) established that children with
ADHD demonstrate more negative behaviours in play
(e.g. disruptions and rule violation). Cordier, Bundy,
Hocking and Einfeld (forthcoming) observed that within
the context of play, children with ADHD present with
less interpersonal empathy. We are not aware of any
studies that investigate similarities or differences in the
play of children with different ADHD subtypes.
This study is part of a larger investigation in which we
compared the play of children with ADHD with that of
children without ADHD. However, only the children
with ADHD are discussed in this study. In this work, we
examined whether the play of children with the three
subtypes differed in ways that would be predicted by
known differences in their cognitive processing, psychosocial abilities and tendency to develop comorbidities, as
cited earlier. For the purposes of this study, play was
defined as a transaction between the individual and the
environment that is intrinsically motivated, internally
controlled, free of many of the constraints of objective
reality and framing-related skills (reading and responding to cues; Bateson, 1971, 1972; Skard & Bundy, 2008).
Play manifests in children as playfulness (i.e. the disposition to play; Bundy, 2004; Neumann, 1971). Most
authors have written about play and playfulness as
though they are synonymous (Barnett, 1991; Skard &
Bundy; Neumann). Using this definition and the Test of
Playfulness (ToP), which operationalises the definition,
we further explored if differing characteristics can be
observed in the play of the ADHD subtypes. We tested
the following hypotheses.
Hypothesis 1: Item hierarchy (i.e. estimated item measure calibrations) will be the same for children with the
HI- and C-subtypes.
Hypothesis 2: Children with ADHD I-subtype will have
lower estimated measure calibrations on ToP items that
reflect intrinsic motivation (i.e. they will find those items
harder) than is predicted by the Rasch model calculated
on all subtypes.
Hypothesis 3: Children with ADHD HI- and C-subtypes
will have significantly lower estimated measure calibrations on ToP items that reflect social skill than is predicted by the Rasch model calculated on all subtypes.
Hypothesis 4: Children with ADHD HI- and C-subtypes
will have significantly higher estimated measure calibrations on ToP items that reflect mischief ⁄ teasing and
clowning ⁄ joking (i.e. they will find those items easier)
and children with the I-subtype will find the same items
more difficult than is predicted by the Rasch model calculated on all subtypes.
Methods
Ethical approval was obtained from the University of
Sydney Human Ethics Research Committee and the
Northern Y Regional Ethics Committee, New Zealand.
Participants
Participants were children aged between 5 and 11 years
who were diagnosed with ADHD (n = 105). The children
were recruited from district health boards and paediatricians’ practices in Auckland, New Zealand. Diagnostic
procedures were followed to ensure high levels of diagnostic accuracy and to minimise the inclusion of borderline cases (i.e. cases just failing to reach the criteria on the
DSM-IV) and cases where diagnoses other than ADHD
were deemed primary. As part of the diagnostic workup, participants went through an initial assessment. If
ADHD was suspected, a Connors’ Parent Rating ScalesRevised (long version; CPRS-R: L) was administered. Furthermore, a school observation was conducted and a
CTRS-R: L was administered. If the findings supported
the diagnosis of ADHD, the child was referred to an
ADHD subunit specialising in the diagnosis of ADHD.
The psychiatrist ⁄ paediatrician then made the diagnosis
of ADHD if the child met the DSM-IV criteria, including
the ADHD subtype.
Children were included if they had conditions commonly associated with ADHD, such as learning disorders, ODD, CD, anxiety disorder and mood disorder.
They were excluded if they had other major neuro-developmental or psychiatric disorders, such as autistic spectrum disorders, intellectual disabilities, movement ⁄ tic
disorders and organic brain syndromes. Additionally,
any children with ADHD who were on medication,
wherein an overnight period was insufficient for washout
(e.g. atomoxetine), were excluded.
After inclusion in the study, an additional CPRS-R: L
was administered to confirm the diagnosis of ADHD.
The CPRS-R: L has three DSM-IV scales that categorise
the child with ADHD into the subtypes. The subtype was
determined by the clinicians and checked against the
CPRS-R: L subtype classification. The agreement between
the clinician classification into the ADHD subtypes and
the CPRS-R classification was 93.8%. There was discordance between the original subtype classification and the
subtype determined by the CPRS-R: L screening for seven
participants, who were then excluded from the study.
The children with ADHD were finally allocated into the
following three ADHD subtype categories: I-subtype
(n = 46), HI-subtype (n = 28) and C-subtype (n = 31).
Each child with ADHD invited a typically developing
playmate (n = 105) to a play session; playmates were of a
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similar age to the children with ADHD and were familiar
to them. For the purpose of this study, ‘typically developing playmate’ is defined as a child (i) who did not have
ADHD (i.e. scored below the clinical cut-off for any of the
CPRS-R subscales and DSM-IV scales) and (ii) for whom
no concerns had been raised about development by a teacher or health professional. Overall, children who were
not proficient in English were excluded because use of
English is necessary for interpreting the ToP by an English-speaking rater.
The mean ages of the respective groups were: I-subtype=
9.2; HI-subtype = 8.9; and C-subtype = 9.2. The remainder
of demographic information for the participants and their
primary caregivers is summarised in Table 1. To assist with
interpretation of the ToP results, the mean CPRS-R: L
subscale scores are summarised in Table 2.
The children with ADHD and their playmates were not
matched on any criteria as the playmates of children with
ADHD were selected by the children with ADHD. This
was carried out to ensure that an unfamiliar playmate
would not influence the play situation, a factor overriding the potential benefit of matching participants within
the ADHD group.
Instruments
The ToP (Bundy, 2004) was used to measure the children’s play. The ToP is a 29-item observer-rated instrument that can be administered to any individual between
the ages of 6 months and 18 years. Each item is rated on
a four-point (0–3) scale. Scores reflect extent (proportion
of time), intensity (degree of presence) or skilfulness (ease
of performance). The ToP measures the concept of playfulness as a reflection of the combined presence of four
elements contributing to a single (unidimensional) construct of playfulness: perception of control, freedom from
constraints of reality, source of motivation and ability to
give and read social cues. Although the ToP was
designed to represent a theoretical conceptualisation of
playfulness comprised of multiple elements, playfulness
is a single construct; thus, it is not feasible to analyse data
by the four elements (Bundy). One overall score on the
scale is calculated with a mean of 50 and a standard deviation (SD) of 10.
The ToP is administered in an environment that is supportive of play and has evidence of excellent inter-rater
reliability (data from 96% of raters fit the expectations of
the Rasch model) and construct validity (data from 93%
of items and 98% of people fit Rasch expectations; e.g.
Bundy, Nelson, Metzger & Bingaman, 2001).
The CPRS-R: L is a paper-and-pencil screening questionnaire completed by parents ⁄ primary caregivers to
assist in determining whether children between the ages
of 3 and 17 years have signs and symptoms consistent
with the diagnosis of ADHD. The CPRS-R: L has evidence of excellent reliability (international consistency
reliability 0.75–0.94) and construct validity (to discriminate ADHD from the non-clinical group: sensitivity 92%,
specificity 91%, positive predictive power 94% and negative predictive power 92%) (Conners, 2004; Conners, Sitarenios, Parker & Epstein, 1998). Conners’ scales have
been found to be effective in the differential diagnosis of
children with the varying ADHD subtypes, with and
without comorbid conditions, when used in combination
with other data sources, such as a diagnostic interview
(Hale, How, Dewitt & Coury, 2001). The primary purpose
of using the CPRS-R: L was to screen children for inclusion into or exclusion from the study, and to assist in the
interpretation of ToP findings.
Procedure
The environment from where the data were gathered
was a playroom set up specifically for the assessment at a
TABLE 1: Participant demographics
ADHD participants
I-subtype
HI-subtype
C-subtype
ADHD subtype ratio
Percentage boys
Percentage girls
Primary caregiver’s highest level of education
Did not complete high school
Completed high school
Completed tertiary qualifications
Primary caregiver’s occupation
Jobs that do not require tertiary qualifications‡
Jobs that do require tertiary qualification
2 (n = 46)†
76.1
23.9
1 (n = 28)†
78.6
21.4
1 (n = 31)†
71.0
29.0
10.9
67.4
21.7
10.7
50.0
39.3
19.4
51.6
29.0
54.3
45.7
64.3
35.7
71.0
29.0
†The attention deficit hyperactivity disorder (ADHD) subtype ratio is similar to the ratio reported in a recent national
Australian representative sample (Graetz, Sawyer, Hazell, Arney & Baghurst, 2001).
‡Tertiary qualifications refer to qualifications obtained after school, that is, qualifications obtained from a college or a
university. C-subtype, combined; HI-subtype, hyperactive-impulsive; I-subtype, inattentive.
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TABLE 2: Connors’ Parent Rating Scale-Revised (CPRS-R) subscale scores
I-subtype
(n = 46)
HI-subtype
(n = 28)
C-subtype
(n = 31)
Subscales
Subscale description
Mean
SD
Mean
SD
Mean
SD
F
P
Oppositional
Break rules, problems with authority,
easily annoyed
Learn slowly, organisational problems
difficulty completing tasks
concentration problems.
Have worries and ⁄ or fears, emotional,
sensitive to criticism, shy, withdrawn
Set high goals, fastidious, obsessive
Have few friends, low self-esteem and
self-confidence, feel emotionally
distant from peers
Report an unusual amount of
aches and pains.
Emotional, cry a lot, get angry easily
Broad-ranged behaviour problems
65.7
12.8
68.4
10.7
79.5†
11.2
13.3
<0.001
73.3†
9.3
68.3
8.4
74.6†
12.9
3.1
0.053
57.3
13.6
53.8
10.4
65.2
11.3
7.0
0.001
53.9
71.3†
11.2
17.6
54.0
74.2†
10.3
10.1
60.2
85.2†
14.2
11.9
3.0
9.0
0.052
<0.001
68.2
18.2
54.3
14.2
66.7
17.4
6.4
0.002
60.6
67.3
13.5
10.2
56.6
71.2†
10.1
6.7
71.0†
83.7†
11.1
10.0
11.9
29.2
<0.001
<0.001
Cognitive ⁄ inattention
problems
Anxious ⁄ shy
Perfectionism
Social problems
Psycho-somatic
Emotional labile
Behavioural problems
†Denotes CPRS-R subscale mean scores above the clinical cut-off (i.e. behavioural problems are significant for the
respective subscales). C-subtype, combined; HI-subtype, hyperactive-impulsive; I-subtype, inattentive; SD, standard
deviation.
clinical site where the children with ADHD came regularly for assessment or intervention. According to Bundy
(2004), the environment should be one in which the child
feels physically and emotionally safe to increase the
chances for spontaneous and intrinsically motivated play
to occur. The categories of the Test of Environmental Supportiveness (TOES) were used as a guideline for establishing play spaces with the maximum chance of
promoting play. The TOES operationalises the ways in
which the four aspects of the environment influence players’ motivation to play: playmates, objects, play space
and the sensory environment (Skard & Bundy, 2008).
The toy selection catered to likely motivations for
engaging in free play arising from gender differences and
age. A diversity of play materials was present in the room
to support a range of play. The same toys were present
during all play sessions and the children were allowed to
choose play materials and activities.
Approximately 60% of the playmates of children with
ADHD were siblings because that proportion of the children with ADHD identified that they did not have
another usual playmate. Parents ⁄ guardians were
requested not to administer medication prescribed for
ADHD on the day of the assessment as we were interested to observe how ADHD affects play without the
effects of medication.
The assessor tried to make the participants feel at ease
prior to the interactive free play session. Each observation
included approximately 20 minutes of playtime. An
assessor was present in the playroom but was as unobtrusive as possible and had been instructed not to intervene
unless a child was in danger. When children attempted to
interact with the assessor, the assessor’s response was
neutral.
The entire interactive free play session was recorded
on videotape by a handheld video camera for purposes
of later scoring. A single experienced rater assessed all
the children using the videotapes. Prior to scoring, the
rater was calibrated on the ToP, which means the consistency of her ratings was compared with that of hundreds
of other raters in a larger ToP sample (N > 3000 observations); her calibration results demonstrated that she is a
reliable rater. To ensure that her scores did not drift, the
rater rescored approximately 20% of the videotapes; these
were randomly selected. Her data from both test administrations were analysed with Facets (see the following
para); scores for each child were compared time 1 vs.
time 2 and found to be equivalent because the overall
scores for no child differed by more than the standard
error of measurement. The rater did not participate in
any other aspect of the study and was blinded to the purpose of the study to minimise bias.
Data analysis
To attain interval-level scores for each participant, the
ToP raw scores were subjected to Rasch analysis using
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the Facets program (version 3.62.0; Linacre, 2007). The
Rasch model enables the researcher to examine simultaneously (i) whether or not the items define a single unidimensional construct (playfulness in this instance); (ii) the
relative difficulty of each test item; and (c) the relative
playfulness of each person taking the test (Bond & Fox,
2007).
In addition to estimates of the relative difficulty of
items and ability of people, the Rasch analysis yields
goodness-of-fit statistics expressed in MnSq and standardised values. Prior to further calculations, we examined
the goodness-of-fit statistics for people and items to
ensure that they were within an acceptable range set
a priori (MnSq < 1.4; standardised value < 2; Bond & Fox,
2007); this ensured that the measured scores were true
interval-level measures.
Bias-interaction analysis, also called differential item
functioning (DIF), generated by Facets, was used to examine whether the relative difficulty of the ToP items differed significantly for one or more of the three subgroups
of children with ADHD (I-subtype vs. HI-subtype vs. Csubtype). DIF occurs when people from different groups
with the same latent trait (in this case playfulness) have a
different probability of giving a certain response on a
questionnaire or test (Embretson & Reise, 2000). DIF analysis, expressed in t-values, provides an indication of how
different the scores of the subgroups were on each item.
An item displays statistically significant DIF when a
t-value is ‡1.96, indicating that the difficulty level estimated by Facets for that item differed across groups
(Wendt & Surges-Tatum, 2005). Because we hypothesised
no more DIF in each of these items, considered one at a
time, than could occur by accident, we considered each
t-test to stand by itself. Thus, we did not apply Bonferroni
(or other similar) adjustments (J. M. Linacre, personal
communication, 17 June 2008). The significance level was
set at P £ 0.05.
The need for DIF was suggested by a pattern of
unexpected ratings (i.e. scores that were unexpectedly
low or high, given a child’s overall level of playfulness).
These unexpected ratings were associated primarily with
eight items reflecting intrinsic motivation, social skill or
mischief ⁄ clowning. Of the 87 unexpected ratings
awarded, 76 (87%) were associated with these items.
DIF also can be used to ensure equivalence of the
groups with respect to potentially confounding variables.
We tested the effects of nine such variables: (i) gender, (ii)
age (in three bands: 5–6, 7–8 and 9–11 years), (iii) ethnicity, (iv) socio-economic status, (v) younger vs. older sibling playmates, (vi) age difference between playmate
pairs, (vii) sibling vs. non-sibling playmate pairs, (viii)
clinically significant ODD symptoms vs. non-clinically
significant ODD symptoms and (ix) clinically significant
anxiety symptoms vs. non-clinically significant anxiety
symptoms. None of the listed confounding variables was
found to be significantly different between groups
(P < 0.05).
Results
DIF analysis revealed no differences in item hierarchy for
children with the HI- and C-subtypes. Thus, Hypothesis
1 was supported.
As hypothesised, children with the I-subtype had significantly lower estimated measure calibrations than predicted by the Rasch model on one intrinsic motivation
item: ‘intensity of engagement (22)’. Children with the
I-subtype found this item to be much easier than had
been predicted by the model calculated on all the subtypes. However, they did not find any other items reflecting intrinsic motivation to be easier than predicted. Thus,
Hypothesis 2 was only partly supported.
Also as hypothesised, children with the HI- and C-subtypes had estimated item calibrations that were significantly higher (easier) and children with the I-subtype had
estimated item calibrations that were significantly lower
(harder) than predicted on ‘mischief (17)’ and ‘clowning
(19)’. Furthermore, children with the HI- and C-subtypes
had estimated item calibrations that were significantly
lower (harder) on five social skill items: ‘initiating play
(1)’, ‘sharing (4)’, ‘supporting the play of others (5)’,
‘social play (12)’ and ‘responding to play cues (29)’. Thus,
Hypotheses 3 and 4 were fully supported.
The t-values generated by bias interaction to compare
scores on each item for the children in the different subtypes with those expected by the Rasch model are provided in Table 3, together with their corresponding item
descriptions. An item-by-item comparison of the subtypes is illustrated in Figure 1. In the remainder of the
study, the ToP item numbers, as shown in Table 3, are
used in brackets for reference.
Discussion
When we examined the play patterns of children representing the three ADHD subtypes, we found that they
were very similar for children with the HI- and C-subtypes, supporting the mounting evidence for the case that
they are overall alike. Children with the I-subtype differed in ways that would be predicted by known differences in cognitive processing, psycho-social ability and
comorbidity. Furthermore, because none of the confounding variables that we tested accounted for the
observed differences and because the rater was blind to
the purpose of the study, the differences are very likely to
be the result of actual differences among the subtypes.
‘Intensity of engagement (22)’, which measures the
degree to which a player is concentrating on the activity
and is thought to reflect intrinsic motivation, was significantly more difficult than predicted by the overall Rasch
model for children with the I-subtype. Because the play
situation was designed to be particularly appealing, these
findings partially support Diamond’s (2005) hypothesis
that the primary problem of children with the I-subtype
is decreased motivation rather than inattention.
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TABLE 3: Test of Playfulness item descriptions and t-values (for an indicator of differential item functioning) for attention deficit
hyperactivity disorder subtypes
t-value*
Item
Perception of control
1 – Skill of initiating play
2 – Skill of negotiating needs
3 – Extent of deciding what to do
4 – Skill of sharing ideas or objects
5 – Skill of supporting the play of others
6 – Intensity of interacting with objects
7 – Skill of interacting with objects
8 – Skill of modifying task requirements
9 – Skill of transitioning between activities
10 – Extent of playing with others
11 – Intensity of playing with others
12 – Skill of playing with others
Freedom from constraints of reality
13 – Extent of pretending
14 – Skill of pretending
15 – Extent of using people ⁄ objects unconventionally
16 – Skill of using people ⁄ objects unconventionally
17 – Extent of using mischief ⁄ teasing
18 – Skill of using mischief ⁄ teasing
19 – Extent of using clowning ⁄ joking
20 – Skill of using clowning ⁄ joking
Source of motivation
21 – Extent of being engaged
22 – Intensity of being engaged
23 – Extent of being involved in the process
24 – Intensity of persistence
25 – Intensity of showing positive affect
Framing (play cues)
26 – Skill of being engaged
27 – Extent of giving cues
28 – Skill of giving cues
29 – Skill of responding to cues
I-subtype
HI-subtype
C-subtype
3.58†
)1.47
0.13
3.63†
3.88†
)0.50
)0.17
)0.05
)0.20
0.16
0.46
4.00†
)2.07†
0.90
)0.58
)2.19†
)2.58†
0.27
1.24
1.25
0.28
)0.66
)0.42
)2.12†
)2.25†
1.10
0.00
)2.07†
)2.15†
0.60
)0.80
)0.99
0.19
0.73
0.07
)2.66†
)1.06
)0.58
)0.43
)1.08
)3.59†
)0.59
)4.10†
)0.81
0.82
0.57
)1.07
)0.75
2.10†
0.08
3.00†
0.47
0.42
0.05
1.40
1.85
2.25†
0.59
2.10†
0.39
)0.57
)2.36†
0.30
0.63
)1.01
0.05
1.65
)0.41
0.57
0.69
0.92
1.52
0.22
)1.30
0.58
)0.29
)0.81
)0.61
3.61†
0.43
0.55
0.42
)2.03†
0.01
0.73
0.61
)2.25†
*t-values reflect the direction and significance of the distance from the estimated parameter. †Values of significance
(t-values > 1.96; t-values < )1.96). C-subtype, combined; HI-subtype, hyperactive-impulsive; I-subtype, inattentive.
However, our results did not support Baeyens et al.’s
(2006) findings that children with the I-subtype experience difficulty in ‘skill to transition ⁄ shift between activities (9)’ or with ‘persistence (24)’. That is, our findings
suggest that although children with the I-subtype experienced difficulty with intense involvement, they persisted
with activity that they did find to be motivating.
Children with the HI- and C-subtypes struggled on
several social items. This is in line with previous findings
that children with the HI- and C-subtypes have a
tendency to butt in and take things from others; are
unable to wait their turn; are not considerate of others’
feelings (Diamond, 2005) and have a tendency to initiate
play in destructive ways or fail to initiate play at all. Perhaps these characteristics collectively help explain why
children with the HI- and C-subtypes are more likely
than children with the I-subtype to be rejected by peers
(Diamond).
Children with the HI- and C-subtypes also found ‘playful mischief (17)’ and ‘clowning (19)’ to be relatively
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I-subtype
5
HI-subtype
C-subtype
Freedom from constraints of
Reality
Perception of control
Motivation
Framing
Diagnosis: t-value relative-to-overall (+)
4
3
2
+1.96
1
0
–1
–1.96
–2
–3
–4
28. GiveCues_S
29. RespondCues_S
27. GiveCues_E
25. Affect_I
26. Engaged_S
24. Persist_I
23. Process_E
22. Engaged_I
21. Engaged_E
20. ClownJoke_S
19. ClownJoke_E
18. MischiefTease_S
17. MischiefTease_E
16. Unconventional_S
14. Pretend_S
15. Unconventional_E
13. Pretend_E
11. SocialPlay_I
12. SocialPlay_S
10. SocialPlay_E
8. Modifies_S
9. Transitions_S
6. InteractObject_I
7. InteractObject_S
4. Share_S
5. Support_S
3. Decide_E
1. Initiate_S
2. Negotiate_S
–5
FIGURE 1: Bias interaction of attention deficit hyperactivity disorder subtypes and Test of Playfulness items.
easier than predicted, whereas children with the I-subtype found them to be more difficult. These findings may
reflect previous research, suggesting that children with
the HI- and C-subtypes are more extroverted, less selfconscious and more animated than children with the
I-subtype. In contrast, children with the I-subtype are
known to be more introverted, self-conscious and passive
(Barkley, 2003; Diamond, 2005; Gaub & Carlson, 1997);
their more self-conscious play style was particularly evident in relatively lower scores on ‘clowning’ (19) and
‘mischief’ (22).
Previously, we suggested that the constellation of low
ToP scores of children with ADHD, compared with those
of typically developing children, was indicative of difficulty with interpersonal empathy (Cordier et al., forthcoming). In coming to this conclusion, we employed a
three-part definition of empathy described by Feshbach
(1997): (i) ability to discriminate and identify the emotional state of another; (ii) capacity to take the perspective
of another; and (iii) evocation of a shared affective
response. We proposed that difficulties with empathy
were reflected in low scores on several ToP skill items
considered together: ‘supporting the play of others (5)’,
social play (12)’, ‘responding to play cues (29)’ and sharing (4)’. However, the current findings suggest that
reduced empathy may be more characteristic of children
with the HI- and C-subtypes than those with the I-subtype.
Lack of empathy combined with wilful non-compliance is characteristic of ODD and subsequent CD (American Psychiatric Association, 2000; Loeber, Burke, Lahey,
Winters & Zera, 2000), two conditions that commonly cooccur, particularly in children with HI- and C-subtypes.
Whereas mischief, by ToP definition, is not wilful noncompliance, several authors (Lahey & Loeber, 1994) have
suggested that the behaviour of children with ADHD
deteriorates across the lifespan. For some children, mischief and clowning may begin as a means of trying to
engage other players. However, if unsuccessful (as
unskilled mischief often is), it may turn into defiant
behaviour (e.g. breaking important rules and committing
aggressive acts). A possible link between mischief and
oppositional behaviour of children with the HI- and
C-subtypes is supported by concomitant high CPRS-R
Oppositional Subscale scores and higher than expected
ToP scores on extent of ‘mischief (17)’ and ‘clowning (19)’
(see Tables 2 and 3).
Limitations
It was not feasible to draw a random sample. Hence, the
ability to generalise the results of this study to children
with ADHD in other populations is somewhat limited.
However, the strength of the results indicates the need
for further research.
Conclusions and implications for
research and practice
Our results reveal similarities in play patterns of children
with HI- and C-subtypes and the possibility of a different
hierarchy of ToP items for children with the I-subtype
compared with those of children with the other two subtypes. Nonetheless, variability within the subgroups suggests that an individual child may be quite different from
other children within the same subgroup. Therefore, the
findings support the need to evaluate play for all children
with ADHD and to target interventions to individual
needs, particularly as play is the milieu within which
children develop social skills and form peer relationships
(Barkley, 2006). Further research is needed to replicate
2010 The Authors
C 2010 Australian Association of Occupational Therapists
Journal compilation C
144
R. CORDIER ET AL.
the findings. Specifically, further research is needed to
determine if children with the I-subtype respond differently from children with the other subtypes to play-based
interventions.
Although our findings cannot, and should not, replace
assessment of play in an individual child, they do suggest
that there are enough differences in the play patterns of
children with the I-subtype compared with that of children with the HI- and C-subtypes to warrant consideration when planning intervention to improve play. For
example, when therapists plan interventions for children
with the I-subtype, it may be advantageous to include the
usual playmate of the child with ADHD into the intervention. In fact, a usual playmate may help the child to
counteract a typically passive style of interacting. Intervention might encourage the children to engage in playful mischief to increase the fun, capture the source of
their motivation and promote engagement. Conversely,
the following will more often need to be considered when
planning interventions for children with the HI- and
C-subtypes, helping a child: identify the emotional state
of a playmate, take on a playmate’s perspective, share
affective responses, understand the boundaries of playful
mischief and clowning, initiate play activities appropriately and support the play of a playmate.
Acknowledgements
This study was completed by the first author as part of
the requirements for the completion of a PhD under the
supervision of the other authors. The authors wish to
acknowledge the Australian Government for EIPRS and
IPA scholarships, and express their gratitude to the
families who participated in the research, and in particular to the staff from Whirinaki, Kari and Marinoto
North Child and Adolescent Mental Health Services,
New Zealand.
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