Australian Occupational Therapy
Journal
Australian Occupational Therapy Journal (2011) 58, 231–240
Research Article
A play-based intervention for children with ADHD:
A pilot study
Sarah Wilkes, Reinie Cordier, Anita Bundy, Kimberley Docking and
Natalie Munro
Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia
Introduction: Many children with attention deficit
hyperactivity disorder (ADHD) have serious social and
peer difficulties that can lead to adverse outcomes in adoles-
cence and adulthood. To date, psychosocial treatments have
produced poor outcomes in reducing social impairments
commonly associated with ADHD. This study aimed to
examine the efficacy of a new intervention designed to
improve the play and social skills of children with ADHD
and their playmates within the natural context of play.
Methods: Participants included children (aged 5–11
years) diagnosed with ADHD, age-matched typically devel-
oping playmates (n = 14 ⁄ group) and parents of children
with ADHD. The intervention involved seven weekly
video-recorded free-play sessions; video feed-forward ⁄
feedback and therapist- and peer-modelling were used to
promote social play. The Test of Playfulness was used as a
pre- ⁄ post-test measure. Data were subjected to Rasch analy-
sis to calculate measure scores on interval level; dependant
sample t-test and Cohen-d calculations were used to mea-
sure effect.
Results: A dependant samples t-test revealed that both
children with ADHD (t = 8.1; d.f. = 13; P < 0.01) and
their playmates (t = 6.9; d.f. = 13; P < 0.01) improved in
their social play. Results demonstrated a large effect in
improving the social play of children with ADHD
(d = 1.5) and their playmates (d = 1.3).
Sarah Wilkes BAppSc (OT) Hons; Occupational Therapist.
Reinie Cordier PhD; Lecturer, Discipline of Occupational
Therapy. Anita Bundy ScD; Chair of Occupational Therapy.
Kimberley Docking PhD; Lecturer, Discipline of Speech
Pathology. Natalie Munro PhD; Lecturer, Discipline of
Speech Pathology.
Correspondence: Reinie Cordier, Faculty of Health Sciences,
Cumberland Campus, The University of Sydney, Rm J121,
J Block C43J, 75 East Street, Lidcombe, NSW 2141, Australia.
Email: reinie.cordier@sydney.edu.au
Accepted for publication 7 February 2011.
C 2011 The Authors
C 2011 Occupational
Australian Occupational Therapy Journal
Recent research indicates that the social impairments
Therapy Australia
doi: 10.1111/j.1440-1630.2011.00928.x
Discussion: Results support the use of play, video feed-
forward ⁄ feedback techniques, therapist- and peer-modelling
and parent involvement as an effective means to develop
the social play skills of children with ADHD. Further
larger-scale research is required.
KEY WORDS decentering, empathy, peer-modelling,
social problems, video self-modelling.
Introduction
Attention deficit hyperactivity disorder (ADHD) is a com-
mon childhood neurobehavioural disorder characterised
by developmentally inappropriate levels of inattention,
hyperactivity and impulsivity (American Psychiatric
Association, 2000). Social dysfunction is common in chil-
dren with ADHD which frequently leads to peer rejection,
and having fewer meaningful friendships (Hoza et al.,
2005; Wiener & Mak, 2008). Although stimulant medica-
tion and psychosocial treatments are most commonly pre-
scribed, these treatments have produced poor outcomes
in reducing social impairments (Findling, 2008; MTA
Cooperative Group, 2008; Purdie, Hattie & Carroll, 2002).
This is concerning, as the escalating effect of continuing
social difficulties and peer rejection is likely to cause
adverse outcomes in later life (e.g. high-school drop-out,
antisocial behaviour) and can potentially lead to serious
psychiatric disorders (Bagwell, Molina, Pelham & Hoza,
2001; Barkley, Fischer, Smallish & Fletcher, 2002).
Most psychosocial treatments aim to reduce negative
social behaviours by teaching children socially acceptable
behaviours within a controlled therapeutic setting (Whalen
& Henker, 1991). The limited effectiveness of such interven-
tions could in part be explained by a number of factors,
including delivering the treatment within a group context
rather than in dyads, limited parental involvement and sim-
ply targeting poor social skills, rather than the underlying
cause of the social impairment (Antshel & Remer, 2003).
Lack of interpersonal empathy in children
with ADHD
of children with ADHD may be attributed to lack of
232
interpersonal empathy, rather than simply poor social
skills (Cordier, Bundy, Hocking & Einfeld, 2010a; Marton,
Wiener, Rogers, Moore & Tannock, 2008). This finding is
supported in Barkley’s (1997) model, suggesting that chil-
dren with ADHD are less empathetic, and demonstrate a
lack of responsiveness to the needs, emotions and view-
points of others. Empathy is associated with prosocial
behaviour and comprises both affective and cognitive
components involving the ability to: (i) discriminate and
identify the emotional states of another, (ii) take on the
perspective or role of another and (iii) evoke shared affec-
tive responses in the context of mutually enjoyed, reci-
procal interactions (Feshbach, 1997). Furthermore,
childhood development theory denotes that pretend play
is central in developing emotional understanding and by
early school age, children are better able to take on oth-
ers’ viewpoints and are less occupied with their own
viewpoint; they become more decentered (Piaget, 1962;
Stagnitti, 2009).
Cordier et al. (2010a) observed that the play of children
with ADHD is characterised by a developmentally inap-
propriate lack of empathetic responding. This is observed
in their difficulty to: support the play of others, respond
to others’ play cues, share and interact in a cooperative
manner; highlighting their preoccupation with having
their own play needs met. Cordier et al. offered lack of
empathy as an explanation of how these play deficits
impacted on the children’s ability to develop play trans-
actions as well as form and maintain meaningful friend-
ships. Based on the results of their study, Cordier et al.
developed a model for an intervention aimed at enhanc-
ing the social play skills of children with ADHD (Cordier,
Bundy, Hocking & Einfeld, 2009). The model for a play-
based intervention was developed on the assumptions
that play is an important childhood occupation and the
natural context within which children develop complex
social behaviours and competence.
Play-based intervention principles
The model embraces four important principles: (i) captur-
ing the intrinsic motivation of children; (ii) facilitating the
development of interpersonal empathy; (iii) including a
regular playmate and; (iv) active parent involvement.
Furthermore, during the initial phase of the pilot inter-
vention we noted the importance of therapist modelling
to reinforce all intervention strategies. Therefore, we
added a fifth intervention principle: therapist-modelling.
The intervention was first concerned with capturing
the intrinsic motivation of children with ADHD. There-
fore, the environment was set in an inviting playroom
which the child perceived as emotionally and physically
safe, supportive of free play. When a child with ADHD
engages in play that is intrinsically motivated, they are
more likely to experience an increased ability to maintain
attention and persist through difficult situations, allow-
ing a play transaction to be fully developed (Bundy, 2004;
Cordier et al., 2009).
Australian Occupational Therapy Journal
S. WILKES ET AL.
To facilitate the development of interpersonal empa-
thy, the process of decentering was encouraged (i.e. dis-
criminating and identifying the emotional states of
playmates, taking on playmates’ perspectives or roles
and evoking shared affect). Techniques including self-
modelling (using adapted video feed-forward and video
feedback techniques) and therapist-modelling were used
to shift the behaviour of children with ADHD away from
their tendency towards domination, destruction and self-
focus (Cordier et al., 2009).
Playmates were included to promote peer-modelling
and friendship development. Although there is limited
research on the playmates of children with ADHD, recent
findings suggest that to a lesser degree they too display
negative behaviours (Cordier, Bundy, Hocking & Einfeld,
2010b). Therefore, familiar playmates were included as
we postulate that they would also benefit from the inter-
vention and thus become better equipped to support chil-
dren with ADHD. Parents were key in reinforcing the
application of intervention techniques to different con-
texts and to facilitate the continuity of skill development.
These techniques were incorporated into the intervention
as they have been found to be effective in improving play
and social skills in different population groups (Dowrick,
1999; Frankel, Myatt, Cantwell & Feinberg, 1997; Wolf-
berg, 2003).
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 skills
related to framing (giving and responding to cues) (Bate-
son, 1972). Play manifests in children as playfulness (i.e.
the disposition to play) (Bundy, 2004; Neumann, 1971).
Using this definition and the Test of Playfulness (ToP),
which operationalises the definition, we set out to
develop and test the efficacy of a play-based intervention.
Applying the previous four principles, the intervention
aimed to improve the social play skills of children with
ADHD and their playmates. We tested the following
hypotheses:
d Hypothesis 1: The mean overall ToP post-test score of
children with ADHD will be significantly higher than
the mean overall pre-test score.
d Hypothesis 2: The mean overall ToP post-test score of
playmates of children with ADHD will be signifi-
cantly higher than the mean overall pre-test score.
d Hypothesis 3: The mean post-test scores of children
with ADHD will be significantly higher than their
pre-test scores on ToP items that reflect interpersonal
empathy.
Methods
Participants
The participants recruited for the study included two
groups of children (n = 15 ⁄ group) between the ages of 5
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ADHD PLAY-BASED INTERVENTION 233

and 11 years. Group 1 involved children diagnosed as
having ADHD and Group 2 involved typically develop-
ing children without ADHD. One child with ADHD was
paired with one typically developing child. The play
pairs were known to each other to avoid unfamiliar peers
influencing the results in unacceptable ways. Play pairs
were matched by age a priori to cater to developmental
needs (i.e. the maximum age difference between play
pairs was three years; mean age difference = 0.3 years;
SD = 0.96). All participants were required to be proficient
English speakers. Parents of children with ADHD also
participated in the study. One family discontinued their
participation because of pressing family commitments;
thus, the findings are reported on n = 14 ⁄ group.
Children with ADHD (Group 1)
Children with ADHD were recruited from local paediat-
ric services and primary schools and through a media
release. To be included in the study, children had a for-
mal and unambiguous diagnosis of ADHD made by a
psychiatrist or paediatrician using recognised diagnostic
procedures (i.e. meeting the criteria for ADHD as defined
in the Diagnostic and Statistical Manual of Mental Disorders,
4th edition [DSM-IV]). Children with comorbid condi-
tions that commonly coexist with ADHD (e.g. learning
disorders, oppositional defiant disorder) were included,
provided ADHD was the primary diagnosis. However,
children diagnosed with major neurodevelopmental or
psychiatric disorders (e.g. autism spectrum disorder,
intellectual disability and cerebral palsy) were excluded.
In addition to the formal diagnosis made by a paedia-
trician or psychiatrist, the presence of ADHD symptoms
was confirmed a priori by parent ratings on the Conners’
Parent Rating Scale-3rd edition (CPRS-3) and the Child
Behavior Checklist (CBCL; Achenbach & Rescorla, 2001;
Conners, 2008; i.e. ratings above the clinical cut-off,
t-value ‡ 70 on the DSM-IV subscales of the CPRS-3 and
CBCL). To assist with the interpretation of the ToP (Bun-
dy, 2004) results, the CPRS-3 subscale scores which pro-
vide a behavioural representation of participants are
summarised in Table 1. Children were included in the
study regardless of their medication status. Parents were
asked to maintain the consistency of the type and dose of
medication throughout the course of the intervention ses-
sions and to report any changes; deviations in medication
and health concerns were recorded on a weekly basis.
Typically developing playmates (Group 2)
Children in Group 2 were invited by a child with ADHD;
they were similar in age and a regular playmate (in some
cases a sibling). For the purposes of this study, a typically
developing playmate was defined as a child who did not
have ADHD as defined by the DSM-IV criteria for ADHD
(i.e. scored below the clinical cut-off for all of the CPRS-3
and CBCL subscales) and for whom no concerns were
raised about development or behaviour by a teacher or
health professional. Typically developing playmates who
scored in the borderline clinical range for the CPRS-3 and
the CBCL (t-values ‡ 65; t-values < 70) were excluded.
Parents of children with ADHD
At least one parent or primary carer was present during
all intervention sessions. Where possible both parents
attended. The demographic information of participants is
summarised in Table 2.
Instruments
Test of Playfulness
The ToP (Bundy, 2004) was the primary assessment tool
used to measure the children’s play. The ToP is a 30-item,
observer-rated instrument suitable for children and teens

TABLE 1: Conners’ Parent Rating Scales-3rd edition subscale scores

ADHD Playmates

Subscale item Item description Mean† Mean

Hyperactivity symptoms Never sit still; act as if driven by a motor 80.1† 47.0
Inattention symptoms Forgetful; easily bored; sluggish 85.0† 49.1
Learning problems Cognitive problems; slow learning; distracted 76.0† 46.9
Executive functioning Lacks: problem-solving; insight; planning 76.2† 52.7
Aggression Loses temper; easily annoyed; resentful 84.4† 58.5
Peer relations Social problems; few friends; isolation 85.2† 54.8
Inattentive subtype Predominately inattentive symptoms 78.2† 49.8
Hyperactivity ⁄ impulsivity subtype Predominately hyperactive ⁄ impulsive symptoms 76.6† 46.5
Conduct behaviour Bullies; threatens; uses weapons; violent 78.1† 56.2
Oppositional behaviour Opposes authority; rejects, breaks rules 77.5† 50.3

†Conners’ Parent Rating Scales-3rd edition subscale mean scores are above the clinical cut-off (i.e. subscale scores > 70).
All subscale items for attention deficit hyperactivity disorder (ADHD) and playmate groups: d.f. = 13; P < 0.01.

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234 S. WILKES ET AL.

TABLE 2: Participant demographics is a well-established measure for assessing behaviours

consistent with ADHD. The CPRS-3 has evidence for
Group 1 Group 2 excellent reliability and construct validity; internal con-
Variables ADHD playmates sistency (0.89), temporal stability (0.86) and inter-rater
reliability (0.83). The CPRS-3 was found to be a valid
Mean age (SD) (years) 7.6 (1.6) 7.3 (1.6) measure: (i) factorial validity proved to have adequate fit,
Gender (%) (ii) across-informant correlations were consistent
Male† 71.4 57.1 (r = 0.61) and (iii) discriminative validity was found
Female 28.6 42.9 to have high levels of classification accuracy (86.0%;
Ethnicity (%)
Conners, 2008).
Caucasian 64.3 57.1 Child Behaviour Checklist
Asian 21.4 28.6
The CBCL is a standardised parent questionnaire that is
Other ethnicities 14.3 14.3
commonly used in research to establish the frequency
Primary caregiver’s highest level of education (%)
and intensity of behavioural problems of children aged
Completed high school 14.3 21.4
6–18 years. The CBCL was administered to all partici-
Tertiary qualifications: 14.3 14.3 pants as a secondary screening measure to confirm the
Diploma ⁄ certificate absence or presence of current ADHD symptoms as rated
Tertiary qualifications: 71.4 64.3 in the CPRS-3. To be included, children had to meet the
University degree clinical cut-off criteria on both the CBCL and CPRS-3.
Primary caregiver’s occupation (%) The CBCL has proven to be a reliable and valid measure;
Jobs that do not require tertiary 57.1 64.3 internal consistency (0.86–0.91) and test–retest reliability
qualifications (0.85–0.93; Achenbach & Rescorla, 2001).
Jobs that do require tertiary 42.9 35.7
qualifications Procedure
Once ethical approval was received, parents whose chil-
†Ratio 1:3, this is a close approximation to the 1:5 ration dren met the inclusion criteria were contacted and sched-
of boys to girls diagnosed with attention deficit uled to receive seven weekly 40-minute intervention
hyperactivity disorder (ADHD) as reported in the literature sessions. The play-based intervention took place in a con-
(American Psychiatric Association, 2000). SD = standard sistent and inviting playroom (5 m · 5 m with a one-way
deviation. mirror), set up to be supportive of play (Cordier et al.,
2010a). The toys available in the playroom where study
observations were made catered to gender differences,
between the ages of 6 months and 18 years. Each item is the age range of the children and for their likely motiva-
rated on a 4-point (0–3) scale. Scores reflect extent (i.e. tions for engaging in free-play activities. A diversity of
proportion of time), intensity (i.e. degree of presence) or play materials was present in the room to support a range
skilfulness (i.e. ease of performance). The ToP measures of play. Examples of the toys included dress-up clothes,
the concept of playfulness as a reflection of the combined construction toys, a sandbox, and soft bat and ball games.
presence of four elements contributing to a single (unidi- The same toys were present during all play sessions.
mensional) construct of playfulness: perception of con- The children were allowed to choose play materials and
trol, freedom from constraints of reality, source of activities.
motivation and ability to give and read social cues. The
ToP has evidence for excellent inter-rater reliability (data Play-based intervention structure
from 96% of raters fit the expectations of the Rasch Each play pair was allocated a primary and secondary
model); moderate test–retest reliability (e.g. intraclass therapist to promote a positive therapist–child relation-
correlation 0.67 at P < .01; Brentnall, Bundy & Kay, 2008) ship. The primary therapist provided the children with
and construct validity (e.g. data from 93% items and 98% weekly feedback and modelled desired skills in the play-
of people fit Rasch expectations (Bundy, Nelson, Metzger room. Concurrently, the secondary therapist worked
& Bingaman, 2001). closely with the child’s parents. Figure 1 provides a
temporal, schematic representation of the intervention
Conners’ Parent Rating Scales-3 structure.
The CPRS-3 is a screening questionnaire completed by All intervention sessions were video-recorded to facili-
parents to identify children between the ages of 6 and tate self-modelling (using video feedback and feed-
18 years who have current symptoms consistent with a forward) and for ease of scoring. A single non-blinded
diagnosis of ADHD. The CPRS-3 was selected as the pri- therapist scored the video recording of the children’s
mary screening tool to confirm the presence or absence of play against the ToP following each intervention session.
current ADHD symptoms. The CPRS-3 was selected as it Prior to scoring the sessions, the therapist was calibrated

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ADHD PLAY-BASED INTERVENTION 235

Intervention structure

Baseline play (pre-test)
Orient to play environment
Child with ADHD & playmate
Child
Therapist-modeling Therapist-, peer- & Final evaluation (post-test)
Only therapist & child with self-modeling
20 minute video feedback/feed- 20 minute video feedback/
ADHD play (20-minutes)
forward feed-forward

play (30 minutes - first 10
minutes not included in pre-test
score)
Build rapport with child with
ADHD
Therapist demonstrates
strategies to parents as skilled
playmate
20 minute free-play – post test
20 minute free-play
Post-test scored without
Graded therapist modeling -
therapist involvement to match
decreased as children
progressed pre-test

Children & primary therapist

Session 1 >>>>>>>>>>>>>>>>> Session 2 >>>>>>>>>>>>>>>> Sessions 3–6 >>>>>>>>>>>>>>>> Session 7

Parents & secondary therapist

Introduction & education Strategies for developing social Support and training Feedback & continuation
skills through play Observe video feedback & play
Gather client history Feedback: child’s strengths vs. Identify play areas that Topics, strategies, & play-tasks
Parent

Topics: understanding play;
play deficits in children with
ADHD; social skills;
importance of friendship
target areas requiring
development
Play observation: strategies to
develop your child’s target
areas
improved & areas requiring re-capped
further support Child’s overall improvement
Discuss therapist modeling and discussed
how parents can implement Gather parent feedback
strategies at home

Play-tasks (home work): sessions 1 & 2 Play-tasks: sessions 3–6

Gathering information on observed play behaviours at home Implementing intervention strategies at home
Playing with your child Giving the child feedback and problems-solving alternative strategies
Including siblings/playmates in play Facilitating play-dates

FIGURE 1: Intervention structure (not source).

on the ToP. This means that the consistency of her ratings
was compared with hundreds of other raters in a large
ToP sample (n > 3000). The therapist’s calibration results
indicated that she was a reliable rater because her good-
ness-of-fit statistics were within an acceptable range
(MnSq < 1.4; standardised value £ 2; Bond & Fox, 2007).
Children and the primary therapist. The primary therapist
facilitated the self-modelling and free-play sessions (see
Fig. 1). During the self-modelling session, children
observed and reflected on edited video footage of their
social play from the previous week. The therapist used
video feedback techniques by discussing the segments of
their past performance. The therapist then used video
feed-forward techniques by facilitating a problem-solving
discussion with the children, helping them to develop
strategies to preempt the changes required for future
social skill development to occur. To conclude, the thera-
pist presented the children with three key summary
points to remember and preempt as they entered the
playroom. While playing, the therapist supported both
children to engage in prosocial behaviours (e.g. sharing,
supporting and responding). This was facilitated by
engaging in mutually enjoyable social play and by
encouraging joint pretend play. In turn, the playmates
modelled desired social skills and reciprocity.
Parents and the secondary therapist. The secondary thera-
pist worked closely with the child’s parents by providing
education, support training and feedback (see Fig. 1). Par-
ents observed all self-modelling and playroom sessions
through a one-way mirror, completed weekly play tasks
and reviewed their weekly take-home copy of the self-
modelling DVD with their child before the next session.
Parents were encouraged to continue fostering dyadic
friendship development by inviting the playmate or a
peer to their home.
Data analysis
To attain interval-level scores for each participant, ToP
raw scores were entered into an existing database con-
taining scores of children with ADHD and typically
developing children (N = 378). The data were then sub-
jected to Rasch analysis using the Winsteps program (ver-
sion 3.70.0.2; Linacre, 2007).
The resulting measure scores of the sample were then
entered into SPSS (version 18; SPSS Inc, Chicago, IL,
USA) and t-tests for dependent samples were calculated

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236
to compare pre- and post-test mean ToP scores from
Sessions 1 and 7. All significance levels were set at
P < 0.05. A non-parametric one-sample Kolmogorov–
Smirnov test was used to compare the observed cumula-
tive distribution with the expected null hypothesis
distribution. The goodness-of-fit tests if observations
could reasonably have come from the specified distribu-
tion; thus, parametric testing was deemed appropriate.
Cohen-d values were calculated to examine effect size
(Cohen, 1992). Cohen-d effect size sets a benchmark of
0.20 as small, 0.50 as medium and 0.80 as large (Rosnow,
Rosenthal & Rubin, 2000).
Prior to conducting t-tests, differential analysis (i.e.
DIF, differential item functioning), generated by the Win-
steps program, was used to ensure equivalence of the
group with respect to potentially confounding variables
(P £ 0.05). DIF analysis was used to examine the ToP
items to see whether the items have significantly different
meanings for the two groups, indicated by any significant
differences in how children performed on each ToP item
for each diagnostic group (ADHD vs. playmate). We
tested the effects of 12 such variables: (1) gender, (2) age
(in three groups: 5–6, 7–8 and 9–11 years), (3) ethnicity,
(4) socioeconomic status, (5) younger vs. older sibling
playmates, (6) age difference between playmate pairs, (7)
sibling vs. peer playmates, (8) clinically significant oppo-
sitional defiant disorder symptoms vs. non-clinically
significant oppositional defiant disorder symptoms, (9)
clinically significant conduct disorder symptoms vs.
non-clinically significant conduct disorder symptoms,
(10) clinically significant anxiety symptoms vs. non-clini-
cally significant anxiety symptoms, (11) parent-reported
play time at home and (12) children receiving medication
vs. those who did not.
Results
No comparison of data for any potentially confounding
variable was significant (t < 1.96; P < .05). We interpreted
this to indicate that none of the confounding variables
tested (e.g. medication use, age, oppositional defiant dis-
order and anxiety) accounted for the observed changes.
TABLE 3: Effect sizes of the intervention
ADHD
Pre-test Post-test
Mean S1 (range) Mean S7 (range) SD Cohen-d† ES
41.8 (17.9–64.4) 69.2 (50.3–83.0) 18.2 1.5 Large
†Cohen-d effect size (ES) for attention deficit hyperactivity disorder (ADHD) and playmate groups were calculated
separately: Group (mean post-test ) mean pre-test) ⁄ spooled SD for group measure scores. ES was interpreted as large
(‡ 0.80), medium (‡ 0.50) or small (‡ 0.20) in magnitude (Cohen, 1992). Mean and standard deviation (SD) scores were
derived from interval-level measure scores. S1, Session 1 of the intervention; S7, Session 7 of the intervention.
Australian Occupational Therapy Journal
S. WILKES ET AL.
Hypothesis 1: Effect of the intervention on
the play of children with ADHD
The hypothesis that the mean overall ToP post-test score
of children with ADHD will be significantly higher than
the mean overall pre-test scores was supported. A t-test
for dependent samples revealed significance (t > 8.10;
P < 0.01). Furthermore, Cohen’s effect size value (d = 1.5)
suggests a large effect size (see Table 3).
Hypothesis 2: Effect of the intervention on
the play of playmates
The hypothesis that the mean overall ToP post-test score
of playmates of children with ADHD will be significantly
higher than the mean overall pre-test scores was sup-
ported (t > 6.86; P < 0.01). Furthermore, Cohen’s effect
size value (d = 1.3) suggests a large effect size (see
Table 3).
Hypothesis 3: Development of interpersonal
empathy of children with ADHD
The hypothesis that the mean post-test scores of children
with ADHD will be significantly higher than their pre-
test scores on ToP items that reflect interpersonal empa-
thy were partially supported. Empathy, as described by
Feshbach (1997) and applied to the ToP items (see num-
bers denoted in Table 4), comprises (i) the ability to dis-
criminate and identify the emotional states of another
(item 30); (ii) the capacity to take the perspective or role
of the other (items 5, 15, 10); and (iii) the evocation of a
shared affective response (items 6, 13, 12) (Cordier et al.,
2010a). In the remainder of the discussion, the ToP item
numbers, as shown in Table 4, are used in brackets for
reference (e.g. ToP item 5).
DIF analysis results and corresponding t-values are
shown in Table 4. Children with ADHD improved signif-
icantly in four of the seven ToP items that reflect the con-
structs of interpersonal empathy: skill of sharing ideas or
objects (ToP item 5; t = 2.88), skill of supporting the play
of others (ToP item 6; t = 2.76), skill of transitioning
between activities (ToP item 10) (t = 5.32) and skill
of responding to play cues (ToP item 30; t = 2.29). No
Playmates
Pre-test Post-test
Mean S1 (range) Mean S7 (range) SD Cohen-d† ES
56.8 (42.5–75.2) 75.7 (55.3–90.8) 14.7 1.3 Large
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ADHD PLAY-BASED INTERVENTION 237

TABLE 4: Differential item functioning analysis of all children with Test of Playfulness (ToP) item descriptions and corresponding t-
values

ADHD Playmates

Difference Difference
Item S1† S7† in t-value S1† S7† in t-value

Perception of control
1 Extent of playing safely 0.87 0.11 )0.76* )1.75 0.00 1.75*
2 Skill of initiating new activities 0.36 )0.32 )0.68* 0.97 )1.25 )2.22*
3 Skill of negotiating needs )2.08 )0.21 1.87* 0.92 1.48 0.56*
4 Extent of deciding what to do 0.69 )0.82 )1.51* )0.33 0.15 0.48*
5 Skill of sharing ideas or objects† )3.73 )0.85 2.88* 2.28 2.11 )0.17*
6 Skill of supporting the play of others† )3.68 )0.92 2.76* 2.33 2.21 )0.12*
7 Intensity of interacting with objects )0.07 0.89 0.96* )1.14 0.86 2.00*
8 Skill of interacting with objects 0.38 )0.06 )0.44* )0.44 0.12 0.56*
9 Skill of modifying task requirements )0.33 0.81 1.14* 0.14 )0.69 )0.83*
10 Skill of transitioning between activities† )2.76 2.56 5.32* )1.18 1.66 2.84*
11 Extent of playing with others 0.76 0.78 0.02* )0.87 )0.89 )0.02*
12 Intensity of playing with others† 0.64 0.55 )0.09* )0.75 )0.43 0.32*
13 Skill of playing with others† )1.7 )1.47 0.23* 1.36 1.84 0.48*
Freedom from constraints of reality
14 Extent of pretending )0.87 2.31 3.18* )2.10 0.94 3.04*
15 Skill of pretending† )0.98 0.00 0.98* 0.23 0.59 0.36*
16 Extent of using people or objects unconventionally 1.00 1.63 0.63* )2.60 0.20 2.80*
17 Skill of using people or objects unconventionally 0.70 0.27 )0.43* )0.61 )0.32 0.29*
18 Extent of using mischief ⁄ teasing 2.52 )2.17 )4.69* 1.03 )3.2 )4.23*
19 Skill of using mischief ⁄ teasing 0.74 )1.78 )2.52* 0.75 0.29 )0.46*
20 Extent of using clowning ⁄ joking 4.61 )1.24 )5.85* 0.86 )5.06 )5.92*
21 Skill of using clowning ⁄ joking 1.64 )0.46 )2.10* 0.30 )1.65 )1.95*
Source of motivation
22 Extent of being engaged 0.28 )0.12 )0.40* )0.58 0.60 1.18*
23 Intensity of being engaged 0.00 0.82 0.82* )0.64 )0.08 0.56*
24 Extent of being involved in the process )1.12 0.11 1.23* 0.70 0.00 )0.70*
25 Intensity of persistence 0.58 0.42 )0.16* )1.56 0.72 2.28*
26 Intensity of showing positive affect 2.45 0.7 )1.75* )1.60 )2.13 )0.53*
Framing (play cues)
27 Skill of being engaged 0.66 1.17 0.51* )1.54 )0.18 1.36*
28 Extent of giving cues 0.00 )1.00 )1.00* 1.27 )0.53 )1.80*
29 Skill of giving cues )0.83 )1.38 )0.55* 0.90 1.77 0.87*
30 Skill of responding to cues† )3.72 )1.43 2.29* 3.00 1.69 )1.31*

*Item denotes significance (t = > 1.96; > )1.96). †ToP items that represent the constructs of interpersonal empathy.
S1, Session 1; S7, Session 7.

significant improvements were observed for intensity of
playing with others (ToP item 12), skill of playing with
others (ToP item 13) and skill of pretend play (ToP item
15).
Discussion
We set out to examine the efficacy of an innovative inter-
vention aimed at developing the social play skills of chil-
dren with ADHD. In particular, we attempted to improve
the social play of children with ADHD and their play-
mates as measured by the ToP. Furthermore, we aimed to
determine if the ToP items that reflect interpersonal
empathy improved significantly in children with ADHD.
The intervention was based on the model and key princi-
ples proposed by Cordier et al. (2009).
The play-based intervention comprises a unique con-
stellation of techniques aimed at addressing the particu-

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238
lar social play deficits associated with children with
ADHD. The large effect size strongly supports the com-
bined use of video self-modelling, peer- and therapist-
modelling and parent involvement within the context of
play as an effective means to develop the play and social
skills of children with ADHD and their playmates.
Although preliminary in nature, the results are promis-
ing, as few psychosocial interventions have evidence of
efficacy (Antshel & Remer, 2003; Purdie et al., 2002).
Our results support previous research where video
self-modelling was effective in promoting the develop-
ment of social skills in different populations (Dowrick,
1999). We are not aware of any studies where video self-
modelling has been used to improve the social skills of
children with ADHD. We found that by viewing edited
video footage of themselves, children with ADHD were
better able to reflect on their own performance. This
seemed to enable them to develop perspective-taking
and problem-solving skills. Moreover, seemingly
because the technique was novel and captured their
attention, the children were able to recall and demon-
strate changes in skills required to achieve future social
development.
Our findings are similar to those reported by Wolfberg
(2003) for children with autism in response to peer- and
sibling-mediated interventions for enhancing social skills.
We, too, found that the inclusion of a known playmate in
the context of play provided a novel, motivating and
effective means for developing the social skills required
for forming and maintaining meaningful friendships (e.g.
problem-solving, perspective-taking, supporting, shar-
ing, negotiating and creating shared enjoyed experi-
ences).
We realised early into the intervention that therapist-
modelling was required to promote high-quality social
interactions. The therapist engaged in play with the chil-
dren, fostering mutually enjoyed joint play and guiding
both children to engage in prosocial behaviours. That is,
the therapist supported the playmates and helped the
child with ADHD, directly and indirectly, to shift away
from a tendency to control and dominate play. Our obser-
vations suggest that therapist support is critical to the
efficacy of the intervention given the severity of social
skill impairment of children with ADHD and their intru-
sive, disruptive style of social interaction (Wiener & Mak,
2008).
Although children improved significantly in spontane-
ously initiating pretend play themes (ToP item 14), thera-
pist support was essential in evolving the themes by
facilitating joint and cooperative forms of pretend play
between children (ToP item 15). Recent research estab-
lished links between pretend play and social competence,
denoting children who demonstrate less skill in complex
forms of play (i.e. pretend play) are more likely to disrupt
peers or have lower levels of engagement during play
(Uren & Stagnitti, 2009). Furthermore, the importance of
pretend play in developing emotional understanding and
Australian Occupational Therapy Journal
S. WILKES ET AL.
social skills is well documented (Guralnick, Hammond &
Connor, 2003). More so than other types of play, pretend
play facilitated the process of decentering.
In concordance with past research, our results support
the integral role of parents in generalising newly
acquired skills to home and other social environments
and for the continuity of skill development (Frankel et al.,
1997). However, in this study, the evidence of general-
isation to home is only anecdotal; further research is
warranted.
The intervention also resulted in improvements to the
social play of the playmates. This is an important finding
because by improving their social play skills, playmates
are likely to be better equipped to both meet their own
needs in play and support children with ADHD. The
playmates’ ability to ‘persist’ (ToP item 25) during play
transactions improved significantly, thereby supporting a
positive dyadic friendship to develop. Existing literature
strongly supports dyadic friendship development to coun-
teract the negative effects of peer rejection (Bagwell et al.,
2001; Hoza, Mrug, Pelham, Greiner & Gnagy, 2003).
Furthermore, we postulate that in fostering friendships,
we have assisted play pairs to have continued opportuni-
ties to develop their skills post-treatment. That, too,
requires further investigation.
Our results support previous findings that children
with ADHD experience difficulty in ToP items that repre-
sent interpersonal empathy (Cordier et al., 2010a).
Furthermore, post-test results demonstrate that the inter-
vention provides promise in counteracting the effects of
lack of interpersonal empathy, by supporting shift
towards prosocial skill development (decentering). This
was reflected in significant improvement in several ToP
items reflective of empathy (ToP items 5, 6, 10, 30; see
Table 4).
Somewhat surprisingly, ToP items extent of: ‘clowning’
(ToP item 20) and ‘mischief and teasing’ (ToP item 18)
decreased significantly at post-test for both children with
ADHD and their playmates. We speculate that as the chil-
dren developed more effective prosocial mechanisms for
interacting with each other (e.g. supporting, sharing and
responding) that the use of less effective mechanisms
(e.g. clowning and teasing) was no longer needed.
At the end of Session 7, it was evident that some chil-
dren might have benefitted from having more interven-
tion sessions. We postulate that increasing the number of
sessions offered would result in improvements to all ToP
items relating to interpersonal empathy. Therefore, it is
recommended that future research explore a criterion-
based approach.
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 limited. Furthermore,
because of time and resource constraints associated with
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ADHD PLAY-BASED INTERVENTION
preliminary research, the rater was not blinded to the
purposes of the study or to the phase of intervention.
Thus, further research is required.
Conclusions and implications for
research
The purpose of this pilot study was to develop and test
the efficacy of a play-based intervention aimed at
improving the play and social skills of children with
ADHD. Results support the use of play, self-modelling
techniques (video feed-forward ⁄ feedback), therapist- and
peer-modelling and parent involvement as an effective
means to develop the social play skills of children with
ADHD.
Future research should be geared towards refining
features of the intervention such as: (i) developing an
adjunctive home programme to strengthen generalisation
to other environments; (ii) implementing parent-rated
measures to ascertain if gains are maintained post-treat-
ment; and (iii) employing a criterion-based approach to
determine whether extending the number of intervention
sessions would further the skill development of children
more severely affected. Additionally, future research
should ultimately be directed towards trialling the inter-
vention with a larger, more representative sample to
determine if the intervention demonstrates efficacy
within the population at large.
Acknowledgements
The authors wish to extend their gratitude to the families
who participated in the research and Dee Why Rotary
Club for providing financial support.
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