Australian Occupational Therapy Journal (2009) 56, 332–340
doi: 10.1111/j.1440-1630.2009.00796.x
Research Article
Blackwell Publishing Asia
A model for play-based intervention for children
with ADHD
Reinie Cordier,1 Anita Bundy,1 Clare Hocking2 and Stewart Einfeld3
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 3Faculty of Health Sciences, Brain and Mind Research
Institute, The University of Sydney, Sydney, New South Wales, Australia
Background/aim: The importance of play in the social
development of children is undisputed. Even though children
with attention-deficit hyperactivity disorder (ADHD)
experience serious social problems, there is limited research
on their play. By integrating literature on ADHD with
literature on play, we can postulate how play is influenced
by the characteristics of ADHD. These postulations enabled
us to propose a theoretical model (proposed model) to depict
the interactive process between the characteristics of
ADHD and factors that promote play. This paper presents
the revised model and principles for intervention based on
the results of a study investigating the play of children with
ADHD (reported elsewhere).
Methods: We tested the proposed model in a study comparing
two groups of children (n = 350) between the ages of 5 and
11 years. One group consisted of children diagnosed with
ADHD (n = 112) paired with playmates (n = 112) who
were typically developing; the control group consisted of
typically developing children paired with typically developing playmates (n = 126). The Test of Playfulness was
administered, and the model was revised in line with the
findings.
Results and conclusions: The findings suggest difficulties
in the social play and lack of interpersonal empathy in the
play of children with ADHD. We draw on the revised
model to propose preliminary principles for play-based
interventions for children with ADHD. The principles
Reinie Cordier BSocSc Hons (Clin Psych), MOccTher, PhD
Candidate. Anita Bundy ScD, OTR, FAOTA; Chair of
Occupation and Leisure Sciences. Clare Hocking PhD,
MHSc(OT); Associate Professor. Stewart Einfeld MD,
DCH, FRANZCP; Chair, Senior Scientist.
Correspondence: Anita Bundy, Faculty of Health Sciences,
The University of Sydney, PO Box, 170, Lidcombe, Sydney,
NSW 1825, Australia. Email: a.bundy@usyd.edu.au
Accepted for publication 9 March 2009.
© 2009 The Authors
Journal compilation © 2009 Australian Association of
Occupational Therapists
emphasise the importance of capturing the motivation of
children with ADHD, counteracting the effects of lack of
interpersonal empathy, and considerations for including
playmates in the intervention process.
KEY WORDS child development, developmental disorders,
mental health, paediatrics, play.
Introduction
Although there are vast amounts of research on attentiondeficit hyperactivity disorder, and to a lesser extent play
of children with ADHD, there is surprisingly little
research on the sequelae to ADHD conducted in the
context of play. This is particularly unexpected as professionals working with children with ADHD commonly
use play to explore behavioural and social difficulties
and as a medium for intervention (Barkley, 2006). What
limited research there is on the play of children with
ADHD suggests that children with ADHD engage in less
associative and cooperative play compared with typically
developing peers (Alessandri, 1992). Leipold and Bundy
(2000) found that children with ADHD are less playful.
In addition, 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, rule violation).
This paper presents the proposed theoretical model
and a revised model of the play of children with ADHD
based on research findings. A proposed model was
constructed by integrating literature on ADHD with
literature on play and postulating how the characteristics
of ADHD may influence play. This has enabled us to
construct a model that depicts the interactive process
between the characteristics of ADHD and factors that
promote play (play enablers). This proposed model is
based in an accepted definition of play: a transaction
with the environment that is intrinsically motivated,
internally controlled, and free of many of the constraints
of objective reality (e.g. Skard & Bundy, 2008). In keeping
with Bateson (1971, 1972), the proposed model also
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ADHD PLAY MODEL
considers skills related to setting the play frame (i.e.
reading and responding to cues). Using the Test of
Playfulness (ToP) (Bundy, 2004) which operationalises
this definition of play, we set out to construct the model.
The theoretical model is developed on the assumption
that play is important. The importance of play has been
described by many play authors (Sutton-Smith, 1997;
Parham, 2008). Much of children’s early learning is
achieved through play; their physical and socioemotional
and intellectual development is dependent on the quality
of their play (Parham). Play is very often a social experience
(Sutton-Smith). In play, children imitate social actions
and learn to interact (Aeri & Verma, 2004). By modelling
adults, infants enjoy playful intimacy and gain experience
in social reciprocity (Bandura, 1989). They develop more
complex prosocial behaviours such as praising, conversing,
smiling, sharing and waiting for a turn (Power, 2000).
Furthermore, social play promotes active peer engagement
and social competence, which are regarded as ‘cornerstone’
skills that lead to the development of cognitive, social
and cultural competence (Strain & Danko, 1995).
Through play, they imitate adults, learn how to solve
problems, work cooperatively with others and develop
voluntary plans (Parham). It is therefore not surprising
that a child’s playfulness or flexibility of approach has
become a key determinant of whether or not an activity
is play (Skard & Bundy, 2008).
Figure 1 illustrates the proposed model relating the
characteristics of ADHD to play. The centre of the model
represents the play transaction and shows that any
reduction in the elements of playfulness (due to the
presence of ADHD characteristics) needs to be offset by
play enablers. The proposed model also reflects that
the actual ToP items on which children with ADHD
performed significantly better or poorer compared with
typically developing children is still unknown (thus ToP
items are denoted with a question mark). Individual
characteristics of play are represented in superscripts
throughout the narrative description of this model; these
match the numbers in the columns marked ‘Linkages in
Literature’ and ‘Play Enablers’ in Fig. 1. The proposed
model also is described briefly below in relation to
the four elements of playfulness: intrinsic motivation,
internal control, freedom to suspend reality and setting
the play frame.
Intrinsic motivation and ADHD
The motivation to play rests on the premise of a fear-free
environment1 (Moyles, 1989), where tasks are self-selected2,
and players experience success much of the time3
(Malaguzzi, 1998). Furthermore, the impetus for the player’s
involvement stems more from the activity itself than
from an external reward4 (Bundy, 2004). The presence of
intrinsic motivation can be observed, in part, in the
extent to which play is all absorbing and the player gets
completely caught up in the play transaction5 (Bundy;
Csikszentmihalyi, 1990).
The developmentally inappropriate level of inattention
that characterises ADHD is highly situational (Schachar,
1991) and is heightened when tasks are unappealing,
boring or offer little immediate reward6 (Dinklage &
Barkley, 1992). Children who lack motivation for a task
may be unwilling or unable to maintain the effort
required to sustain attention on that task (Barkley, DuPaul
& McMurray, 1990). Consequently, researchers have
suggested that motivational rather than attentional
deficits may explain the behavioral inattention seen in
children with ADHD7 (Diamond, 2005; Dinklage & Barkley).
Apparent hyperactivity is also heightened during
activities with little intrinsic appeal (Wood, 1995). Children
with ADHD may appear hyperactive because they fail
to regulate their activity according to situation or task
demands and constantly move from one task to another8
(Barkley et al., 1990; Dinklage & Barkley, 1992). Postulation:
Children with ADHD who experience decreased motivation to engage in certain play activities may be unwilling
or unable to maintain the effort to sustain attention and
consequently move frequently between tasks (due to
symptoms of inattention and hyperactivity), thereby
causing children with ADHD to be less playful.
Internal control and ADHD
Malaguzzi (1998) emphasised the importance of allowing
children the control to self-initiate tasks as a means of
sustaining intrinsic motivation. Internal control therefore
serves as a mediator for intrinsic motivation9 (Neumann,
1971). Where activities are child-initiated, such as in
play, children are more able to control the outcomes of
an activity10 (Skard & Bundy, 2008). Thus players are
largely ‘in charge of’ their actions and at least some
aspects of the activity’s outcome 11. In short, internal
control enables individuals to be whomever they desire,
and to control material things and make them do whatever
their competence allows12 (Connor, Williamson & Seipp,
as cited in Bundy, 2004).
Self-control, defined as the exercise of internal control
over one’s own actions (Zimbardo, 1985), keeps in check
impulsive, irrational and unacceptable behaviours (Dennis,
1996). Children with ADHD have inadequate self-control
(due to deficient self-regulation and observed as hyperactive and impulsive symptoms), may cause children with
ADHD to feel they are not in control13 (Barkley, 1997).
Postulation: The decreased control over activities and their
outcomes (due to hyperactive and impulsive symptoms)
will cause children with ADHD to be less playful.
Suspension of reality and ADHD
Freedom to suspend reality means that the player is not
bound by unnecessary constraints of reality and is thus
able to choose how close to objective reality a transaction
will be14 (Bundy, 2004). The usual meanings of objects no
longer apply15. The situation is under the control of the
player who has the power to orchestrate it in such a way
as to influence the outcome16,17 (Dennis, 1996). Postulation:
© 2009 The Authors
Journal compilation © 2009 Australian Association of Occupational Therapists
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R. CORDIER ET AL.
Proposed model.
© 2009 The Authors
Journal compilation © 2009 Australian Association of Occupational Therapists
FIGURE 1:
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ADHD PLAY MODEL
The ability to suspend reality depends on taking control.
Children with ADHD who have reduced internal control
will have a decreased ability to suspend reality and
therefore be less playful.
Framing and ADHD
Bateson (1971, 1972) described the player’s ability to give
and respond to social cues as ‘framing’ the context of
play18. Responding to playmates’ cues requires an
understanding of social rules19 and gives players the
possibility to support their playmates20 (Bundy, 2004).
The social behaviours of children with ADHD are seen
as abnormal because they often are inappropriate for
task or environmental demands21 (Barkley, 2006; Fadely
& Hosler, 1992). Evidently, the cumulative effect of
impulsivity, hyperactivity and inattention leads to a
reduction in social functioning (Barkley et al., 1990;
Schachar, 1991; Wood, 1995). Postulation: The decreased
ability of children with ADHD to give and respond to
social cues will cause them to be less playful.
The proposed model described in Fig. 1 provides a
theoretical view of how play might be influenced by the
symptoms of ADHD. We tested the proposed model in a
study comparing two groups of children (n = 350)
between the ages of 5 and 11 years. One group consisted
of children diagnosed with ADHD (n = 112) paired with
playmates (n = 112) who were typically developing; the
control group consisted of typically developing children
paired with typically developing playmates (n = 126).
TABLE 1:
We administered the ToP (Bundy, 2004) in an environment
designed to be particularly appealing. The details of the
study are presented elsewhere (Cordier et al., forthcoming).
The purpose of this paper is to present the revised model
as it was adjusted based on our findings and to present
preliminary principles for play-based interventions for
children with ADHD derived from our findings.
Revised model
The model presented in Fig. 2 depicts the play profile of
children with ADHD and their playmates. This revised
model is discussed under four subheadings: primary
symptoms of ADHD, social dimensions of play, interpersonal empathy and summary of overall differences
between the proposed model (informed by literature)
and the revised model (informed by research findings).
Primary symptoms of ADHD
In contrast with our postulations, none of the ToP items
that related directly to the primary symptoms of ADHD
differed significantly between children with ADHD and
typically developing children, suggesting that the primary
symptoms of ADHD (inattention, hyperactivity and
impulsivity) did not account for the difficulties experienced
by the children with ADHD with regard to play. By
definition, six ToP items relate directly to the primary
symptoms of ADHD. See Table 1 for a summary of the
descriptions of the ToP items and their relationship to
Primary symptoms of attention-deficit hyperactivity disorder (ADHD) and Test of Playfulness (ToP) item
Meaning of low scores
ADHD DSM-IV criteria*
Interpretation using the ToP
‘Initiate new activities (1)’ — players attempt
to initiate play destructively or do not try to
initiate activity that can be readily identified
as play.
‘Intensity of interaction with objects (6)’ —
players do not get involved with objects.
Impulsivity: Often interrupts or intrudes
on others (e.g., butts into games)
Players may tend to initiate play
destructively due to impulsivity.
Inattention: Often has difficulty organising
tasks and activities and loses things
necessary for tasks or activities (e.g., toys).
Inattention: Often fails to give close
attention to details in activities.
Players’ interaction with objects
may be superficial due to
inattention.
Players may have difficulty
adapting play due to inattention.
Inattention: Often has difficulty sustaining
attention in tasks or play activities.
Hyperactivity: Often has difficulty playing
quietly.
Inattention: Often has difficulty sustaining
attention in tasks or play activities.
Hyperactivity: Often has difficulty playing
quietly.
Inattention: Often does not follow through
on tasks.
Players may often have
difficulty focussing on an
activity, due to inattention and
hyperactivity.
Players may interact
superficially due to inattention
and hyperactivity.
‘Modify activities (8)’ — players simply repeat
the activity or the activity does not seem to
evolve.
‘Extent of engagement (21)’ — players often
do not engage in purposefully selected
activity or wanders aimlessly or participates
in a non-focussed activity.
‘Intensity of engagement (22)’ — players have
great difficulty concentrating on the activity.
‘Persist with an activity (24)’ — players have
difficulties following through on activities.
*Excerpts from the DSM-IV criterion for ADHD (American Psychiatric Association, 2000).
© 2009 The Authors
Journal compilation © 2009 Australian Association of Occupational Therapists
Players may have difficulties
persisting due to inattention.
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R. CORDIER ET AL.
Revised model.
© 2009 The Authors
Journal compilation © 2009 Australian Association of Occupational Therapists
FIGURE 2:
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ADHD PLAY MODEL
the characteristics of the primary symptoms of ADHD.
This finding might be explained by the play environment
in which data were collected, which was designed to be
particularly appealing in order to increase the chances
that play occurred. The environment where data were
gathered for children with ADHD was a playroom set
up specifically for the study in a clinical setting where
the children with ADHD came regularly for assessment
or intervention. The play environment for children in the
control group was a designated play area at the respective
schools that children in the control group attended. The
play environment was designed to be appealing in order
to increase chances for spontaneous and intrinsically
motivated play behaviour to occur. Apparently a very
appealing environment does indeed offset the primary
symptoms of ADHD (Diamond, 2005).
Social dimensions of play
The children with ADHD had difficulty with many but
not all ToP social items (i.e. items that require social
interaction to be scored), thus underscoring their social
difficulties. While there was no difference in the proportion
of time children with ADHD and typically developing
children interacted with playmates, the intensity of
that interaction was significantly less for children with
ADHD and they were less skilled at social play than the
children in the control group. Taken together, these
findings suggest that children with ADHD seek out social
interaction as much as typically developing children but
struggle as the transaction develops, perhaps in part
because they have difficulty responding effectively to
their playmates’ cues.
Interpersonal empathy
Our results suggest that children with ADHD have
difficulty identifying the emotional states of their
playmates, taking on their perspectives and sharing their
affective responses (Cordier et al., forthcoming). The
pattern of observations that occurred in the context of
social play suggests a developmentally inappropriate
lack of empathetic responding. As a continued reflection
of their diminished empathy, children with ADHD
seemed to lack insight into the importance of reciprocity;
thus the play frame often was disrupted. These findings
are particularly important because lack of empathy may
have significant implications for prosocial development,
particularly as play is the milieu within which children
develop social skills and form peer relationships (Dodge,
1983). In the extreme, diminished empathy could have
adverse implications for the development of morality
and can potentially lead to antisocial behaviour (Barkley,
1995, 1997).
Summary of overall differences between the
proposed and revised models
Although very similar to the proposed model, the data
led to four modifications in the revised model. First, the
intrinsic nature of the motivation of children with ADHD
was not affected as had been postulated originally. While,
as expected, internal control was severely affected,
surprisingly the ability to suspend the unnecessary
constraints of reality was not. This was due to high
scores on mischief/teasing which have offset low scores
on pretend play. Finally, the children’s ability to frame
play by giving and responding to play cues was affected,
but not as severely as anticipated; they were very able to
give cues but had difficulty responding. The graphic
representation of the revised model of the interactive
play transaction of children with ADHD compared with
typically developing children is depicted in Fig. 2.
Using the revised model to plan
interventions for children with
ADHD
Some of what we learned about the play of children with
ADHD will enable the development of useful guidelines
for a play-based therapy structure. If a model for play-based
therapy is employed as an adjunct therapy for ADHD,
therapists need to consider the following.
Intrinsic motivation
Our findings clearly suggest that addressing the
motivational aspects of play could offset the primary
symptoms of ADHD in a free-play context. Therefore
in planning interventions for children with ADHD,
one of the primary considerations should be to capture
children’s intrinsic motivation. As such, consideration
should be given to setting up a physically and emotionally safe environment and providing opportunities
to choose or develop activities that reflect the things
the child is seeking through play. Capturing children’s
motivations ensures that they engage in the activities
for the sheer pleasure of being involved rather than
for a specific outcome; it also increases their ability
and willingness to sustain attention and to maintain play
themes.
Empathy
The strength of our findings regarding the lack of
interpersonal empathy that was characteristic of the play
of children with ADHD suggests the need to consider
the process of decentering when planning interventions
for children with ADHD. Specifically, features such as
discriminating and identifying the emotional states of
playmates, taking on playmates’ perspectives or roles,
and evoking shared affect are important. Interventions
aimed at decentering that have proved effective include
using nascent collective symbolism where playmates
practice imitation with same symbolic meaning to actions
during pretend play (e.g. both players know that handing
each other pieces of paper represent payment) (Hoffman,
2001) and collective pretend play which involves shared
cooperative activities and joint creation of characters
(Stambak & Sinclair, 1993).
© 2009 The Authors
Journal compilation © 2009 Australian Association of Occupational Therapists
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R. CORDIER ET AL.
Ironically, a very good example illustrating collective
symbolism in pretend play came from a play session we
observed between a boy with ADHD (Evan) and his
friend (Troy). Their play transaction stood out as exceptionally creative and complex and it was characterised
by finely tuned perspective-taking. The boys created a
world of princes and dragons out of simple toys and
sand (collective symbolism — joint creation of characters).
They alternated taking the lead in creating their
imaginary world, sometimes by verbally announcing a
new character with a short description: ‘This can be the
prince who has gone on a journey to find the spiked-back
dragon’, pointing to an oddly shaped piece of wood. On
other occasions they seem to follow each other intuitively, knowing that burying the dragons in the sand
meant that the princes had secured yet another victory
(collective symbolism — imitation with same symbolic
meaning to actions). So absorbed were they in their play
that when the 20-min play session was finished, they
pleaded for more time to kill off the dragons who threatened their kingdom. Upon enquiry, the parent of the
child with ADHD indicated that the boys play for hours
and it is often difficult to get them to go to bed when
they are having a sleep-over.
Studying those children with ADHD whose play is not
affected is useful as it could provide us with important
clues in developing interventions for children with
ADHD whose play is affected. What then enables a child
with ADHD to be so skillful at play while most struggle
to keep the play transaction flowing? The answer is
unclear given that we did not observe the ‘Evan’ playing
with another playmate. ‘Evan’ may simply be a good
player. However having a good friend and playmate also
seemed key. The mother described an intimate friendship lasting many years, which endured even though
‘Evan’ had experienced many challenging times in his
young life as a result of difficulties associated with
ADHD. ‘Troy’ was always there to take his mind off things
when the going was tough at school.
How do we foster friendships for children with
ADHD? Using social skills groups to improve peer
relationships has had mixed results in effectiveness
(Pfiffner, Barkley & DuPaul, 2006). Play seems an obvious
medium, as it is the natural context within which children
learn to socialise and make friends (Power, 2000). While
there is no research specifically on including children
with ADHD in interventions, the idea of including peers
in interventions is supported in general in the inclusive
framework for children with disabilities adopted in
many countries (Turnbull, Stowe, Turnbull & Schrandt,
2007), as it provides children with disabilities with the
opportunity to acquire skills that would not have been
possible if they were grouped together with like children
(Hunt & McDonnell, 2007). Integrating children with
disabilities with typically developing children also is
beneficial to the typically developing children as it
promotes altruism. Therefore it makes sense, both theoreti-
cally and intuitively, to involve and support the playmates
of children with ADHD in interventions.
Considerations in including playmates in the intervention:
Targeting dyadic friendships of children with ADHD
may provide a more realistic means for improving peer
relationships, than attempting to improve peer relationships using social skills training in a group (Hoza, Mrug,
Pelham, Greiner & Gnagy, 2003). Ultimately, the intervention should be geared towards forming friendships as
these potentially counteract the adverse outcomes
associated with peer rejection (Hoza et al.). The friendship between ‘Evan’ and ‘Troy’ clearly demonstrates the
potential protective value of a close friendship for children
with ADHD.
Peer- and sibling-mediated interventions have shown
to be effective in enhancing the social play of children
with autism. Even though difficulties in play are different
for children with ADHD compared with children with
autism, some of the principles used in social play
interventions for children with autism can be considered.
Using peers and siblings as change agents is an example
of such interventions (Strain, 2002). Peer-mediated
interventions assume that training typically developing
peers to initiate, prompt and reinforce social interactions
will result in greater improvements in social play
behaviours than simply having children with autism in
close physical proximity to typically developing peers. A
standard training protocol is used to teach the typically
developing peers to deliver specific social offers (e.g.
‘Do you want to play?’), assuring uniformity and quality
instruction (Strain). Peers role-play with adults until they
have learned the strategies; they are then prompted to
interact with the target children around designated play
materials and activities. External reinforcements are
systematically and carefully faded as the peer acquires
the necessary skills (Strain).
The Integrated Play Group (IPG) model is another
effective intervention using playmates and siblings. By
promoting ‘common focus’ on an activity, the IPG model
has been found to double the amount of interaction with
peers, increase functional object use and decrease manipulative, repetitive and isolated play (Wolfberg, 2003). The
IPG model emphasises arranging the environment to
foster mutually enjoyable social interaction, play and
imaginative experiences (Wolfberg). The target child is
encouraged to engage in and maintain interactions with
peers who, in turn, learn to use a variety of skills (e.g.
getting a friend’s attention, sharing, requesting, organising
play and giving compliments).
Regardless of the approach, interventions for children
with ADHD should be geared towards support of
playmates to help children with ADHD shift their
social behaviour away from the tendency towards
domination and disruption. This can be achieved by
optimising the playmates’ strengths (e.g. perseverance,
adaptability and being process focussed) (Cordier et al.,
2009).
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ADHD PLAY MODEL
While critical to promoting the social development of
children with ADHD, including playmates in intervention
may be difficult. Our work as well as previous research
has shown that children with ADHD tend to affiliate
with other children who experience peer problems
(Cordier et al., 2009; Marshal & Molina, 2003) and
similarly display negative and antisocial behaviour
(Mrug, Hoza & Gerdes, 2001) and their siblings (who
are common playmates) are also at risk of emotional and
behavioural difficulties (Mash & Johnston, 1983). Clearly,
further research on the playmates of children with ADHD
is needed.
Finally, in promoting friendships for children with
ADHD, therapists need to consider the difficulties the
children experience in responding to (and presumably
reading) cues during social play. When they are playing,
all creatures (not only humans), provide clear cues about
how they want to be treated (Bateson, 1971, 1972). For
instance, to initiate social play, dogs adopt a characteristic
posture called the ‘play bow’ — forelegs flexed; rear legs
extended; rump in the air with tail wagging — that they
use as both invitation and commentary. The dog performs
a play bow at the beginning of a play bout, crouching
back into it if a nip is accidentally too hard and the other
dog wants assurance: ‘Don’t worry! Still playing!’ Bateson
(1972, 2000) said it cleverly, ‘The playful nip denotes the
bite, but it does not denote what would be denoted by
the bite (p. 180)’. Children with ADHD need to develop
their own social play language — expressive as well as
receptive — using verbal and non-verbal cues that denote
play and promote the flow of the play transaction.
Conclusions
The importance of play in the social development of
children is undisputed. Findings from our study and
previous studies underscore that the play of children
with ADHD is severely affected, which potentially could
lead to adverse outcomes in adulthood. Literature on
play and ADHD allowed us to propose a model of the
interactive process between the elements of play and the
primary characteristics of ADHD. We then tested and
subsequently revised the model, which we have put
forward in this paper. The revised model of the interactive
process between the elements of play and the characteristics
of ADHD can be used as a guide to plan interventions
for children with ADHD, using play as a medium for
intervention. Such interventions should capture the
children’s motivations, counteract the effects of lack of
interpersonal empathy, and include a playmate who
must be supported actively.
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