Australian Occupational Therapy Journal (2014) 61, 299–307
doi: 10.1111/1440-1630.12124
Research Article
Eighteen-month follow-up of a play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder Sarah Wilkes-Gillan,1 Anita Bundy,1 Reinie Cordier1,2 and Michelle Lincoln1 1 Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, and 2School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
Background/aim: There is a well-documented need for interventions to successfully address the social difficulties of children with attention deficit hyperactivity disorder. This study aimed to further the development of a previously conducted pilot of a play-based intervention. To achieve this, children’s social play outcomes pre–post and 18-month following the intervention were examined by raters unaware of the study’s purpose. Additionally, parents’ experiences of the intervention were explored. Methods: Participants included five children with attention deficit hyperactivity disorder who had participated in a play-based intervention and their typically developing playmates; parents of children with attention deficit hyperactivity disorder also participated. Children and their playmates attended an 18-month follow-up play session and parents participated in semi-structured interviews. The Test of Playfulness was used to measure children’s play outcomes in the context of social play with a peer, pre–post and 18-months following the intervention. Wilcoxon signed-ranks (Z) and Cohen’s-d were used to measure effect. Thematic analysis was used to analyse reoccurring themes from parents’ interviews. Results: Children’s social play outcomes improved pre– post intervention (Z = 2.02; P = 0.04; d = 1.6) and were maintained 18-month post intervention (Z = 0.14; P = 0.89; d = 0.4). Core themes included: the intervention as an enjoyable experience, a common language for
Sarah Wilkes-Gillan BAppSc (OT) (Hons); PhD Candidate, Occupational Therapist. Anita Bundy ScD; Professor, Chair of Occupational Therapy. Reinie Cordier PhD; Associate Professor. Michelle Lincoln PhD; Professor, Deputy Dean. Correspondence: Sarah Wilkes-Gillan, Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, 75 East Street, Lidcombe, NSW 2141, Australia. Email: [email protected] Accepted for publication 18 February 2014. © 2014 Occupational Therapy Australia
talking about play/social interactions, an observable change in children’s skills, transference of skills and the need for support to refresh learnt lessons over time. Conclusions: The intervention demonstrated preliminary and long-term efficacy in developing the social play skills of children with attention deficit hyperactivity disorder. Further research is required to optimise intervention feasibility and parent involvement prior to conducting a large-scale research. KEY WORDS evidence-based practice, programme evaluation, psycho-social intervention development, research related, social skills.
Introduction The profound social difficulties experienced by children with attention deficit hyperactivity disorder (ADHD) are well-documented to continue into adolescence and adulthood (Bagwell, Molina, Pelham & Hoza, 2001; Barkley, 2006; Nixon, 2001). One profound social difficulty that children with ADHD experience is difficulty playing with peers (Cordier, Bundy, Hocking & Einfeld, 2010a). Social play with peers, which is predominant in middle childhood, is known to support the development of complex pro-social skills such as: peer engagement, social competence, cooperation, problem-solving and communication (Bundy, 2012; Florey & Greene, 2008; Gifford-Smith & Brownell, 2003). Pharmacological interventions successfully alleviate ADHD symptoms in some children, whereas there is limited evidence of their effectiveness for improving social skills. Similarly psycho-social interventions have demonstrated minimal effectiveness (Pelham & Fabiano, 2008). Additionally, the feasibility and social validity of traditional social skills training approaches have been increasingly questioned (Antshel & Barkley, 2008; Pelham & Fabiano, 2008). Explanations for the poor outcomes produced by traditional social skills training approaches include: (i) the removal of children from the natural environments
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where they both develop social skills and experience inter-personal difficulties; (ii) lack of parent involvement; (iii) treatment delivered in group contexts which place too great a demand on children developing new social skills; and (iv) a focus on poor social skills without considering the underlying impairment (Antshel & Barkley, 2008; Antshel & Remer, 2003; Pelham & Fabiano, 2008). Over the past decade, there has been increasing focus on developing evidence-based interventions and supporting families to make evidence-based treatment decisions (Eiraldi, Mautone & Power, 2011; Pelham & Fabiano, 2008). Thus, there is an amplified need for evidence-based psycho-social interventions to successfully address the social difficulties of children with ADHD. Such interventions should: (i) build on previous approaches (Antshel & Barkley, 2008); (ii) undergo rigorous development and testing; (iii) have a strong theoretical base (Craig et al., 2013); and (iv) have evidence of effectiveness, feasibility and appropriateness (i.e. the participants’ perspective of the intervention; Evans, 2003).
Guidelines for developing complex interventions Most non-pharmacological health-care interventions are considered complex due to the presence of several interconnected components. Guidelines have been compiled by the United Kingdom’s (UK) Medical Research Council (MRC) to provide structure for the development of complex interventions (Campbell et al., 2000; Craig et al., 2013; Medical Research Council, 2008). The guidelines have been widely used and act to ensure a comprehensive approach to the development, imple-
Refine pilot
How does it work?
How can it be optimised?
Phase 1
Phase 2
Definitive trial
Does it work in controlled settings?
Phase 3
Long term
Does it work in “real-life” settings?
Effective? Feasible? Appropriate?
Theoretical Phase
Central to the first phase for developing complex interventions is the need to establish a theoretical rationale that demonstrates how the intervention is likely to be effective in addressing the identified need. Thus, a sound theoretical base that is congruent with the
Implementation
Why should this work?
Theoretical phase: Theoretical model of the play-based intervention
Evaluation
Theoretical base
Feasibility
Development
Pilot trial
mentation, evaluation and dissemination of such interventions (Campbell et al., 2000). The UK MRC guidelines emphasise a systematic, phase-based approach to researching complex interventions (Fig. 1) (Campbell et al., 2000). The guidelines emphasise that before conducting a full-scale evaluation, a series of pilot studies may be required to optimise and refine the intervention (Campbell et al., 2007; Craig & Petticrew, 2013). Further, the need to collect data on both outcome measures and perceptions of participants during the early phases of intervention development is emphasised (Campbell et al., 2007; Evans, 2003). Applying the above guidelines, this paper aimed to further the development of a play-based intervention (Wilkes, Cordier, Bundy, Docking & Munro, 2011), addressing previous limitations and strengthening its foundation prior to further clinical trials. The play-based intervention, which is in the early phases of development, aims to improve the social play skills of children with ADHD. Social play has been operationally defined as, ‘play within a social context involving peer-to-peer interactions’. Further development of the intervention is important as interventions targeting the social impairments of children with ADHD have demonstrated minimal effectiveness (Antshel & Barkley, 2008).
Phase 4
FIGURE 1: Continuum approach for developing complex interventions. Adapted from: Campbell et al. (2000); Craig and Petticrew (2013); Evans (2003); Medical Research Council (2008). © 2014 Occupational Therapy Australia
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underlying problem and justifies the components of the intervention and the desired outcome is required (Campbell et al., 2000; Medical Research Council, 2008). The play-based intervention undergoing development is based on a conceptual framework developed by Cordier, Bundy, Hocking and Einfeld (2009). Cordier et al. (2009) identified little research on the social play of children with ADHD. This was surprising, as therapists commonly use play as a medium for assessment and intervention of the social difficulties of children (Barkley, 2006; Cordier et al., 2009). By reviewing literature on both ADHD and play, Cordier et al. (2009) developed a theoretical model, postulating how the characteristics of ADHD influence the play of these children. The ‘model for a play-based intervention for children with ADHD’ was developed on the assumption that play is an important childhood occupation and is the natural context, which facilitates a child’s physical, cognitive, social and emotional development (Bundy, 2012; Florey & Greene, 2008). Foundational to the model is the following definition of play: a transaction between players and the environment that is intrinsically motivated, internally controlled, free of the objective constraints of reality (Neumann, 1971) and requires skills related to framing (giving and responding to verbal/nonverbal cues and maintaining the play frame; Bateson, 1972; Bundy, 2004). Using the Test of Playfulness (ToP; Bundy, 2004), which operationalises the above definition a theoretical model was then constructed and tested. To test the initial theoretical model, the authors compared the play of children with ADHD (n = 112) to that of their typically developing playmates (n = 112) and to a control group of typically developing children (n = 126). In pairs (child with ADHD and their typically developing playmate or two children from the control group), children were instructed to play in a room filled with toys. Results indicated that overall, the social play skills of children with ADHD were significantly lower than those of the typically developing children in the control group. However, interestingly, children with ADHD scored significantly higher or similarly to the control group on some relatively difficult ToP items reflecting social play: skill to initiate, skill to negotiate and extent of social play. However, they scored significantly lower on relatively easier ToP items, such as the skill of: sharing, supporting a playmate and responding to cues. The researchers (Cordier et al., 2010a) concluded that the configuration of difficulties seen in the children with ADHD could be described best as poor inter-personal empathy. Feshbach (1997) described empathy to have both affective and cognitive components. When children are observed playing together, the components of empathy can be seen in 7 ToP items: (i) the ability to discriminate and identify the emotional states of others (ToP item: skill of responding to play cues); (ii) the ability to perspective-take (ToP items: skill of sharing, skill of transitioning between activities and
skill of pretend play); and (iii) the evocation of shared affective response (ToP items: skill of supporting others, intensity of social play with another and skill of social play) (Cordier et al., 2010a). Based on these findings, the researchers revised their initial model of play difficulties in children with ADHD and developed principles to serve as the foundation for a play-based intervention for children with ADHD. The model included the following intervention principles: (i) capturing the intrinsic motivation of children, to increase willingness and prolong engagement (their choice of free-play); (ii) facilitating the development of inter-personal empathy through decentring techniques (video feedback); (iii) including a regular playmate, to promote friendship development; and (iv) active parent involvement, to facilitate generalisation of treatment effects (Cordier et al., 2009).
Phase 1: Pilot trial of the play-based intervention As a next step, Wilkes et al. (2011) applied the key principles from the model, to develop and test a play-based intervention. Early into the pilot phase, we realised the importance of a fifth key principal; therapist modelling. This involved a therapist playing in the playroom with the children to promote cooperative play. In the initial trial, the play-based intervention was therapist-led and involved 14 children with ADHD and their playmates (i.e. n = 14/group). Children attended the seven weekly, clinic-based sessions in pairs (child with ADHD and the invited playmate). Each session was 40-minutes. Sessions involved 20-minutes of video feedback followed by a 20-minute play session with a therapist. A primary therapist worked closely with the children, watching videotaped play interactions from the previous week. Children were shown 3-minutes of video footage containing things they did well and things to improve. The therapist helped the children to discuss what they did well and how it helped them have more fun with their friend. The therapist also facilitated a problem-solving discussion to help the children identify things they needed to remember to change (e.g. playing alone, not watching or listening to another). Acting as a playmate to the pair, the therapist then modelled desired social interactions in the playroom. Concurrently, a second therapist worked with the children’s parents. The second therapist and parents observed sessions through a one-way mirror. The second therapist provided feedback on playroom observations, including interactions between children and the techniques used in the playroom by the primary therapist. The therapist also discussed the application of techniques at home and how parents could provide their child with feedback on their social interactions before, during and after play with peers. The ToP (Bundy, 2004) was used to examine child outcomes in the context of social play with a peer. © 2014 Occupational Therapy Australia
302 Overall playfulness of the children and changes on the seven ToP items which reflect the construct of inter-personal empathy (Cordier et al., 2010a; Feshbach, 1997; Wilkes et al., 2011) were selected as outcomes in this study. The intervention demonstrated efficacy for improving the social play skills of children with ADHD (t = 8.1; P = 0.01; d = 1.5). However, methodological limitations included: lack of follow-up of child outcomes, lack of blinded ratings on the observational outcome measure and lack of participant feedback regarding intervention appropriateness (i.e. impact of the intervention from the participants’ perspective). Therefore, further development was required to test and strengthen the scientific rigour of the initial pilot study.
Phases 1 and 2: Refining the initial pilot trial The purpose of this study was to test and strengthen the scientific rigour of the initial pilot study (Wilkes et al., 2011), ensuring a scientific foundation prior to ongoing testing. Previous pre-test and post-test efficacy findings were rescored by raters who were unaware of the purposes of the study. Specifically, this study aimed to: (i) test if treatment effects were maintained 18months following the intervention; and (ii) explore the appropriateness of the intervention by ascertaining parents’ experience of the intervention. We hypothesised that children’s gains would be maintained 18-month following their involvement in the play-based intervention. The following research question was then used to investigate parents’ experience of the intervention: What were parents’ long-term experiences and perceptions of intervention appropriateness?
Methods Participants Following ethical approval from the University of Sydney’s Human Research Ethics Committee, families of children with ADHD who participated in the playbased intervention 18-month prior (n = 14; Wilkes et al., 2011) were invited to participate in the current study. Due to time constraints (i.e. participation during school term 1, 2012), only 5 of 14 families were available to participate. Recruitment yielded five boys with ADHD. Four mothers and one father also participated. All participants were Caucasian. Additional demographic information about the children and their parents is reported in Table 1. The current participants were compared with the original group on all demographic variables; they differed on only one: inattention. As measured by the Conners Comprehensive Behavior Rating Scale (CCBRS; Conners, 2008), inattention was found to be significantly lower in the current sample of children (Z = 2.03; P = 0.04).
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TABLE 1: Participant demographics
Parents Parent demographic variables Mean age in years (SD) Caregiver’s education: University degree (%) Primary caregiver’s occupation Jobs that do not require tertiary qualifications Jobs that do require tertiary qualifications Child Child demographic variables Mean age in years (SD) Gender: Male ADHD symptomology Hyperactivity symptoms Inattention symptoms Conduct behaviour Oppositional behaviour Generalised anxiety disorder Academic difficulties Social problems ADHD subtypes Predominantly inattentive Predominantly hyperactive/Impulsive Combined subtype Medication taken for ADHD Sibling as playmate
Participants
Playmate
45.4 (7.2)
44.2 (5.0)
60 (%) 80
60 80
20
20
8.9 (1.6) 5 of 5
8.7 (1.7) 4 of 5
73.20† 75.80† 67.40 79.80† 75.40† 72.20† 75.00†
54.60 56.60 53.20 65.00 58.40 54.40 74.00‡
1
–
2 2 4 of 5 4 of 5
– – – –
†Conners Comprehensive Behavior Rating Scales mean scores are above the clinical cut-off (i.e. subscale scores > 70. ‡Playmates scored above the clinical cut-off (> 70) on ‘social problems’ (non ADHD symptom subscale); this profile supports literature that postulates playmates of children with ADHD may mirror the negative behaviours exhibited by the child with ADHD (Cordier, Bundy, Hocking & Einfeld, 2010b).
Children included in the current study had a primary diagnosis of ADHD, without inclusion of other major neurodevelopmental or psychiatric disorders and were between the ages of 6–11 years. The DSM-IV1 and CCBRS (Conners, 2008) were used to confirm the diagnosis of ADHD (i.e. ratings above the clinical cut-off,
1
At the time the study was conducted, the DSM-V had not yet been published.
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T-scores ≥ 70 on the DSM-IV subscales of the CCBRS). Children continued to take any previously prescribed medications at the time of their 18-month follow-up. Parents reported no new medications or therapies had commenced in the last 18 months. Children with ADHD invited a typically developing playmate to participate. To avoid unfamiliar playmates influencing the results in unacceptable ways, the child pairs were regular playmates. For the purposes of this study, a regular playmate was a child (including a peer, cousin, sibling, neighbour) aged 6–11 years who engaged in regular social interactions with the child with ADHD as determined by the parents of the children with ADHD. The pairs were also of a similar age (maximum age difference = 3.1 years; mean difference = 2.1 years; SD = 0.7). Playmates did not have ADHD as defined by the DSM-IV criteria (i.e. scores below the clinic cut-off for all CCBRS subscales) and parents/teachers had not raised concerns about the playmates’ development or behaviour.
Instruments Test of Playfulness The ToP (Bundy, 2004) was used as the primary pre-, post- and follow-up test measure. Using the ToP, children’s overall play skills were investigated in the social context of peer-to-peer play interactions. The ToP is a 29-item observer-rated instrument that is suitable for children aged 6 months to 18 years. Each item is rated on a 4-point scale to reflect extent, intensity or skilfulness. The ToP measures the concept of playfulness as a reflection of four elements: internal control, freedom from unnecessary constraints of reality, intrinsic motivation and framing (i.e. the ability to give and read social cues). The ToP has evidence for excellent inter-rater reliability (data from 96% of raters fit the expectations of the Rasch model); moderate test–retest reliability (e.g. intra-class correlation 0.67 at P < 0.01; Brentnall, Bundy, & Kay, 2008) and construct validity (e.g. data from 93% items and 98% of people fit Rasch expectations; Bundy, Nelson, Metzger & Bingaman, 2001).
Conners Comprehensive Behavior Rating Scales (CCBRS) The CCBRS (Conners, 2008) was used as a screening measure to provide a profile of child symptomology. The CCBRS is a well-established research and clinical measure for assessing symptoms consistent with childhood disorders, including ADHD. The parent-rated questionnaire is suitable to describe children aged 6– 18 years. The CCBRS has good evidence for reliability and validity: Cronbach’s alpha 0.67 to 0.97, 2–4 week test–retest reliability coefficient .56 to .96 (P < 0.001), inter-rater reliability coefficients .50 to .89 (P < 0.001), discriminative validity (mean overall classification accuracy 78% across all forms; Conners, 2008).
Procedure The 18-month follow-up assessment took place over one week and involved both a parent interview and a 30-minute clinic play session. The second author interviewed parents over the phone, before a follow-up visit to the clinic. The follow-up play session was conducted by the first and third authors and involved each playpair (child with ADHD and playmate) playing in a playroom without a therapist. In the follow-up session, the two children were shown the toys around the playroom, video camera and one-way mirror/observation room where adults would be. The playroom was set up with inviting play materials that were selected to promote social interactions and free-play activities between children (Cordier et al., 2009). Toys included: an indoor basketball hoop and balls, a sandbox, dress-ups, play dough, balloons, soft bat and ball games, foam objects, construction and figurine toys, tea-set and small tent. The first or third author reminded each play-pair (child with ADHD and playmate) that they would be filmed while playing without an adult for about 20-minutes. Children were reassured they would get to play with the therapist again after the 20-minutes. Children were again reminded of the playroom rules: (i) try not to hurt each other; (ii) come out of the room if you need to tell an adult something; and (iii) have as much fun as you can. The first or third author and the child’s parents observed the children playing from behind a oneway mirror. The therapist then re-joined the children in the playroom for 10-minutes which was not videotaped.
Ratings of children’s play All sessions were video recorded to allow for scoring of children’s social play skills by one of five trained and calibrated raters who were unaware of the purposes of the study. The pre- and post-video footage from the previously conducted play-based intervention (re-analysed) (Wilkes et al., 2011) and the 18-month follow-up sessions were rated for each child. A total of 15 video recorded sessions were randomised and allocated to one of five calibrated raters. No rater scored more than one tape for any child. Calibration of raters on the ToP involved scoring eight existing videotaped segments and comparing their ratings with hundreds of other raters who had viewed the same videotapes, using Rasch analysis. Data from all five raters yielded goodness-of-fit statistics were within acceptable range (MnSq < 1.4; standardised value ≤ 2; Bond & Fox, 2007), demonstrating their consistency as raters.
Semi-structured interviews Semi-structured interviews were used to ascertain parents’ experiences of the intervention. The second author, who was not closely involved with the families, conducted individual semi-structured interviews at the 18-month follow-up. The parent who was most involved © 2014 Occupational Therapy Australia
304 in the intervention participated. Parents (4 mothers and 1 father) were asked about: their/their child’s experience of the intervention they had participated in 18 months prior and about their child’s social interactions over the previous 18 months. Interviews were between 40 and 60 minutes in length. All interviews were audiorecorded and transcribed verbatim.
Data analysis To attain interval-level scores, ToP raw scores were entered into an existing database containing scores of both children with ADHD and typically developing children (= 378). Data were then analysed using Facets (version 3.70.1; www.winsteps.com/facpass.htm), a Rasch analysis program. Facets-generated person measure scores were entered into IBM SPSS version 19 for further analysis. To examine if child outcomes were maintained 18 months following the intervention (and to re-examine pre- to post-efficacy findings), Wilcoxon signed rank tests for related samples were calculated to compare mean ToP scores. The data included re-analysed preand post-video footage from the original study’s baseline and post-test. The post-test data were then included in the analysis with the 18-month follow-up data. Cohen’s-d values were calculated to measure effect. Given the small sample size, a conservative approach using non-parametric statistics was adopted (Siegal & Castellan, 1988). All significance levels were set at P < 0.05. Cohen’s-d values were interpreted as: small, ≥ 0.20; medium, ≥ 0.50; or large, ≥ 0.80 (Cohen, 1992). To analyse parents’ interview responses, thematic analysis by means of an open and axial coding process was employed (Strauss & Corbin, 1990). Each transcript underwent manual coding whereby texts were separated into discrete parts. Data of similar content were then grouped. These groupings were converged to form sub- and core-themes. Data interpretation was checked using peer review processes (Strauss & Corbin, 1990). The first and fourth authors independently conducted the initial stages of manual coding. Thereafter, both authors compared and reviewed the groupings of themes. Themes were then re-examined and modified until consensus was reached. Sub- and core-themes were then reviewed by all authors.
Results The hypothesis that children would maintain gains 18month after the play-based intervention was supported. Wilcoxon signed rank tests for related samples revealed that there was no significant difference in children’s social play skills between the mean overall 18-month follow-up measure scores and mean overall post-test measure scores (Z = 0.14; P = 0.89 and d = 0.4). Lack of significant results are interpreted to indicate no significant regression 18-month post intervention. © 2014 Occupational Therapy Australia
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TABLE 2: Effect sizes of the intervention for children with ADHD Post-test
18-month follow-up
Mean S7† (range)
Mean S18† (range)
SD
Cohen’s-d ‡
18-month following play-based intervention 73.1 (63.5–85.3) 69.0 (53.1–79.4) 9.8 0.4
Pre-test
Post-test
Mean S1† (range)
Mean S7† (range)
Pre–post play-based intervention 46.1 (31.7–56.5) 73.1 (63.5–85.3)
ES
Small
SD
Cohen’s-d‡
ES
16.6
1.6
Large
†S1 = Session 1 of the intervention; S7 = Session 7 of the intervention; S18 = 18-month baseline following the intervention. ‡Cohen-d effect size (ES) were calculated by: Group (mean post – mean pre-test)/pooled SD for group measure scores (Cohen, 1992). SD, standard deviation.
The re-examination of pre–post efficacy findings revealed that the mean overall post-test scores were significantly higher than the mean overall pre-test scores (Z = 2.02; P = 0.04; d = 1.6) and that effect size was large (i.e. > 0.80; Cohen, 1992). These findings were similar to those previously reported (d = 1.5; Wilkes et al., 2011) (Table 2). Thematic analysis of parents’ interview responses revealed five core-themes: (i) the intervention as an enjoyable/positive experience; (ii) a common language for talking about play and social interactions; (iii) an observable change in children’s play, social, regulation and language skills; (iv) improved relationships resulting from transference of skills to the home and school; and (v) the need for support to refresh and reinforce learnt lessons over time. All participant quotes are presented in “italics” and pseudonyms are used.
Intervention as an enjoyable/positive experience For both parents and children, one important benefit was the positive experience of attending the intervention. Playing/observing play, interacting with therapists and engaging in video self-modelling was an enjoyable and supportive learning experience, “Ben really enjoyed himself! They enjoyed coming, they enjoyed the playtime, they really enjoyed seeing themselves on the DVD [video self-modelling].” “The [therapist] modelling – that worked really well for Ryan, having someone in there [playroom], playing with him and showing him how. I think the DVDs
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were good as well. . .watching it [previous play interactions] and talking about the play.”
Common language for talking about play and social interactions The predominant benefit to parents was “some really useful, common language for talking about play and all the strategies.” “It gives us as parents, ways to support them during socialisation. . .a shared child-appropriate language to talk about it [social interactions] with the kids, in ways they can work their way out of that problem without being destructive, or us having to solve it.” “They learnt little catch phrases [video self-modelling/common language] and learnt to pace themselves more”.
Observable change in children’s play, social, regulation and language skills For children, parents spoke about ongoing observable changes in their child’s skills in the 18-month following the intervention. Parents spoke about changes in their children’s play with peers, “particularly good in the way that it helped them through their play together – that was the real cause of a lot of arguments” and social skills “he’s making his own friendships really well too”. Additionally, parents spoke about observed changes in their child’s self-regulation. “He’s a high energy child. . .so he’s learnt to sort of stop and he thinks”, and language skills “He tended to be more responsive. He started talking more about things that would happen – so he was feeling able to access the language to describe the experience and feelings more.”
Improved relationships resulting from transference of skills to the home and school Parents stated that their children’s newfound skills transferred to the home and school environments, which led to improved sibling relationships and the development of friendships. “Daniel has developed a lot more love for his brother.” “Harrison made some new friends [at school]. . .three good friends, which he didn’t have before. . .he would always play by himself.” It had a big impact and the school noticed it! Ryan’s behaviour improved a lot at school. . .it helped his confidence with other kids, there seemed to be less conflict with other kids in the playground and less of a miss-fit socially. He learnt a lot about how to play and listen to other people – he had some recipes of how to go about it.
Need for support to refresh and reinforce learnt lessons over time The final core-theme reflected a parent identified need for “top-ups” [of the intervention strategies] to support them as they continued to use the intervention strategies over time. Parents recognised their involvement in the intervention as a valued experience, from which
they continued to use the strategies over time. “So that’s why we’ve been playing, to gently steer him to make good choices”. Parents also discussed the continuing nature of their child’s interactional difficulties and the importance of continuing the strategies to help their child. They can use the skills that come out of it [intervention], play is an ongoing issue to work on, not one of these issues that just goes away – you have to keep working on it to get better”. “If they take a bit away, if their language changes a bit and their attitude towards a person, if they’re a bit kinder and more considerate – I’m thrilled! At the end of the day, we’re all here for Daniel.
Parents also identified the need for support and refreshing of material, so they could continue assisting and supporting their child over time, “We just need refreshing. . .to see it and hear it all again. To practice it more and reinforce it at home. . .doing it again and being all refreshed.” “There’s a lot I’ve forgotten. If I read it, I’ll remember it. . .the problem I have - is my husband wasn’t involved. . .reinforcing it. It’s only me and I don’t do it all the time.” “A problem comes up every second week and we need to be on top of it every week. It’s a lot of work!” And into the future, “Next year, they’re [friends] not in the same class. . .and in high school. . .he’ll have to learn the whole thing again. . .so he needs the basics now.”
Discussion The purpose of this study was to further develop the play-based intervention for children with ADHD by building on the foundations of the initial pilot study (Wilkes et al., 2011). Specifically, we conducted an 18month follow-up to investigate if gains in social play skills were maintained over time and to examine parent perceptions of the intervention. We hypothesised that children’s gains from the intervention would be maintained in the long-term. Child outcome data, as measured by the ToP (Bundy, 2004) and as described by parents, indicated that children maintained gains in their social play skills 18-month following participation in the play-based intervention (Z = 0.14; P = 0.89 and d = 0.4). Although the intervention (Wilkes et al., 2011) was intensive and involved two therapists, long-term intervention effectiveness is important. The results are promising, as few psychosocial interventions have evidence of effectiveness (Antshel & Barkley, 2008; Antshel & Remer, 2003; Pelham & Fabiano, 2008). Additionally, ensuring children with ADHD maintain gains in empathy and pro-social skills is essential as these difficulties are known to continue into adolescence and adulthood (Bagwell et al., 2001; Nixon, 2001). In particular, empathy and pro-social skills such as: sharing, cooperating, supporting another, perspective-taking and negotiating are needed for the
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306 development of reciprocal friendships (Bundy, 2012; Florey & Greene, 2008). Having a friend is important as research demonstrates children who overcome social difficulties are more likely to have positive long-term outcomes than those who continue to experience problems with peers (Barkley, 2006; Fabiano et al., 2009). Moreover, in supporting dyadic friendships, a characteristic of this intervention, we expect that participating children may have attained another important benefit – a genuine friend, although that remains to be studied. Consistent with recommendations from recent literature, the inclusion of naturalistic contexts in which social skills are developed (dyadic play with peers and parent involvement) likely contributed to children maintaining gains in the long-term (Antshel & Barkley, 2008; Antshel & Remer, 2003; Cordier et al., 2009; Pelham & Fabiano, 2008). Reasonably, by including parents and peers, it is likely that children were also exposed to and benefited from ongoing supported play opportunities after the intervention has finished. Parents’ interview responses confirmed that the playbased intervention was a positive, enjoyable and beneficial experience for both themselves and their children. Parents further reported that they continued to use the intervention strategies with their child for some time after the intervention and that their child’s newly gained skills transferred to the home and school environments. We postulate parents continued the use of strategies due to their practical and repetitious nature, which could have reinforced target skills and resulted in continued use (O’Neill, Rajendran & Halperin, 2012). Very likely, these factors contributed to the long-term maintenance of the children’s gains. Parents also gained from the intervention; they developed skills to foster positive interactions with their child. In particular, parents discussed that the intervention provided them with a “common language” that served as a basis for problem-solving with their child around social interactions in ways their child responded to. It is hypothesised that this common language: (i) enabled parents to support their child to regulate their emotions and (ii) assisted children to pre-empt the social skills they required in peer-interactions. Promoting positive parent–child interactions is important as parents of children with ADHD often experience high levels of relational frustration, low levels of parenting confidence and the tendency to be critical of their children’s social interactions (Anastopoulos, Guevremont, Shelton & DuPaul, 1992; Mikami, Jack, Emeh & Stephens, 2010). We believe that the support parents received led to: (i) increased social opportunities with their children and (ii) a means to construct positive feedback before, during and after social interactions (Mikami et al., 2010). Parents also spoke about the play, social, language and self-regulation skills their children gained from participation in the intervention. It is likely that the inclusion of peers assisted with the maintenance and © 2014 Occupational Therapy Australia
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generalisation of skills from the clinic to home and school. We found that the inclusion of a known peer in the context of play provided children with ongoing opportunities to develop social skills needed for friendships; including: problem-solving, perspective-taking, supporting, sharing and negotiating skills (GiffordSmith & Brownell, 2003).
Limitations Only 5 of 14 participants attended the 18-month followup. The small, non-randomised sample limits generalisation of results to the broader population of children with ADHD. Further research is required.
Conclusions The play-based intervention, situated in a strong theoretical foundation, has now been shown, preliminarily, to be effective in both the short- and long-term. These findings set the stage for continued development and refinement of the intervention (Campbell et al., 2000; Medical Research Council, 2008). In line with the guidelines for developing complex interventions, further pilot testing is required before a larger-scale randomised trial can be conducted (Campbell et al., 2000, 2007; Craig et al., 2013).
Future research The aim of subsequent pilot trials would be to refine and optimise the intervention (Campbell et al., 2000, 2007; Craig et al., 2013). Specifically, we see the need for a manual for use by parents. A manualised parent component could serve a dual purpose: to promote effective parent involvement and to reduce costs associated with the second therapist. Further, measuring parent–child relationships could add to our understanding of intervention outcomes (Ginsburg, 2007). Such information would be useful for the later phases of intervention development; whereby programme allocation (i.e. mode of intervention delivery, intervention length or design) may be influenced by parent–child relationship variables.
Acknowledgements The authors extend their gratitude to the participating families. The authors also wish to acknowledge the award of the APA from the Australian Government and financial support from the Rotary Club of Mosman.
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Antshel, K. & Remer, R. (2003). Social skills training in children with attention deficit hyperactivity disorder: A randomized-controlled clinical trial. Journal of Clinical Child and Adolescent Psychology, 32, 153–165. Bagwell, C., Molina, B., Pelham, W. & Hoza, B. (2001). Attention-deficit hyperactivity disorder and problems in peer relations: Predictions from childhood to adolescence. Child Adolescent Psychiatry, 40, 1285–1292. Barkley, R. (2006). Comorbid disorders, social and family adjustment, and subtyping. In R. Barkley (Ed.), Attention deficit hyperactivity disorder. A handbook for diagnosis and treatment (3rd ed., pp. 184–218). New York: Guilford. Bateson, G. (1972). Toward a theory of play and fantasy. In: G. Bateson (Ed.), Steps to an ecology of the mind (pp. 14– 20). New York: Bantam. Bond, T. & Fox, C. (2007). Applying the Rasch model: Fundamental measurement in the human sciences (2nd ed.). Mahwah, NJ: L Erlbaum. Brentnall, J., Bundy, A. C. & Kay, F. C. S. (2008). The effect of the length of observation on Test of Playfulness scores. OTJR: Occupation, Participation and Health, 28(3), 133–140. Bundy, A. (2004). Test of playfulness (ToP). Version 4.0. Sydney, Australia: The University of Sydney. Bundy, A. (2012). Children at play: Can I play too? In: S. Lane & A. Bundy (Eds.), Kids can be kids: A childhood occupations approach (pp. 28–43). Philadelphia, PA: F. A. Davis Company. Bundy, A., Nelson, L., Metzger, M. & Bingaman, K. (2001). Validity and reliability of a test of playfulness. Occupation, Participation, and Health, 21, 276–292. Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A., Sandercock, P., Spiegelhalter, D. et al. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal, 321, 694–696. Campbell, N., Murray, E., Darbyshire, J., Emery, J., Farmer, A., Griffiths, F. et al. (2007). Designing and evaluating complex interventions to improve health care. British Medical Journal, 334, 455–459. Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159. Conners, C. (2008). Conners Comprehensive Behavior Rating Scales. Toronto, Canada: Multi-Health Systems Inc. Cordier, R., Bundy, A., Hocking, C. & Einfeld, S. (2009). A model for play-based intervention for children with ADHD. Australian Journal of Occupational Therapy, 56, 332–340. Cordier, R., Bundy, A., Hocking, C. & Einfeld, S. (2010a). Empathy in the play of children with ADHD. Occupation, Participation, and Health, 30, 122–132. Cordier, R., Bundy, A., Hocking, C. & Einfeld, S. (2010b). Playing with a child with ADHD: A focus on the playmates. Scandinavian Journal of Occupational Therapy, 17, 191–199. Craig, P. & Petticrew, M. (2013). Developing and evaluating complex interventions: Reflections on the 2008 MRC guidelines. International Journal of Nursing Studies, 50, 585–587. Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I. & Petticrew, M. (2013). Developing and evaluating complex interventions: The new Medical Research Council
307 Guidance. International Journal of Nursing Studies, 50, 587–592. Eiraldi, R., Mautone, J. & Power, T. (2011). Strategies for implementing evidence-based psychosocial interventions for children with attention-deficit/hyperactivity disorder. Child Adolescent Psychiatric Clinics of North America, 21, 145–159. Evans, D. (2003). Hierarchy of evidence: A framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12, 77–84. Fabiano, G., Pelham, W., Coles, E., Gnagy, E., Chronis-Tuscano, A. & O’Conner, B. (2009). A meta-analysis of behavioral treatments for attention deficit/hyperactivity disorder. Clinical Psychology Review, 29, 129–140. Feshbach, N. (1997). Empathy: The formative years: Implications for clinical practice. In: A. C. Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy (pp. 33–51). Washington, DC: American Psychological Association. Florey, L. & Greene, S. (2008). Play in middle childhood. In: L. Parham & L. Fazio (Eds.), Play in occupational therapy for children (2nd ed., pp. 279–299). St. Louis, MO: Mosby. Gifford-Smith, M. & Brownell, C. (2003). Childhood peer relationships: Social acceptance, friendships, and peer networks. Journal of School Psychology, 41, 235–284. Ginsburg, K. (2007). The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics, 119, 182–191. Medical Research Council. (2008). Developing and evaluating complex interventions. Retrieved 20 December, 2012, from http://www.mrc.ac.uk/complexinterventionsguidance Mikami, A., Jack, A., Emeh, C. & Stephens, H. (2010). Parental influences on children with Attention-Deficit/ Hyperactivity Disorder: I. Parental behaviors associated with children’s peer relationships. Journal of Abnormal Child Psychology, 38, 721–736. Neumann, E. (1971). The elements of play. New York: MSS Information. Nixon, E. (2001). The social competence of children with attention deficit hyperactivity disorder: A review of the literature. Journal of Child Psychology and Psychiatry Review, 6, 172–180. O’Neill, S., Rajendran, K. & Halperin, J. (2012). More than child’s play: The potential benefits of play-based interventions for young children with ADHD. Expert Review of Neurotherapeutics, 12, 1165–1167. Pelham, W. & Fabiano, G. (2008). Evidence-based psychosocial treatments for attention-deficit/hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 37, 184–214. Siegal, S. & Castellan, N. (1988). Nonparametric statistics for the behavioral sciences (2nd ed.). New York: McGraw-Hill. Strauss, A. & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage Publications Inc. Wilkes, S., Cordier, R., Bundy, A., Docking, K. & Munro, N. (2011). A play-based intervention for children with ADHD: A pilot study. Australian Occupational Therapy Journal, 58, 231–240.
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doi: 10.1111/1440-1630.12124
Research Article
Eighteen-month follow-up of a play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder Sarah Wilkes-Gillan,1 Anita Bundy,1 Reinie Cordier1,2 and Michelle Lincoln1 1 Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, and 2School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
Background/aim: There is a well-documented need for interventions to successfully address the social difficulties of children with attention deficit hyperactivity disorder. This study aimed to further the development of a previously conducted pilot of a play-based intervention. To achieve this, children’s social play outcomes pre–post and 18-month following the intervention were examined by raters unaware of the study’s purpose. Additionally, parents’ experiences of the intervention were explored. Methods: Participants included five children with attention deficit hyperactivity disorder who had participated in a play-based intervention and their typically developing playmates; parents of children with attention deficit hyperactivity disorder also participated. Children and their playmates attended an 18-month follow-up play session and parents participated in semi-structured interviews. The Test of Playfulness was used to measure children’s play outcomes in the context of social play with a peer, pre–post and 18-months following the intervention. Wilcoxon signed-ranks (Z) and Cohen’s-d were used to measure effect. Thematic analysis was used to analyse reoccurring themes from parents’ interviews. Results: Children’s social play outcomes improved pre– post intervention (Z = 2.02; P = 0.04; d = 1.6) and were maintained 18-month post intervention (Z = 0.14; P = 0.89; d = 0.4). Core themes included: the intervention as an enjoyable experience, a common language for
Sarah Wilkes-Gillan BAppSc (OT) (Hons); PhD Candidate, Occupational Therapist. Anita Bundy ScD; Professor, Chair of Occupational Therapy. Reinie Cordier PhD; Associate Professor. Michelle Lincoln PhD; Professor, Deputy Dean. Correspondence: Sarah Wilkes-Gillan, Discipline of Occupational Therapy, Faculty of Health Sciences, The University of Sydney, 75 East Street, Lidcombe, NSW 2141, Australia. Email: [email protected] Accepted for publication 18 February 2014. © 2014 Occupational Therapy Australia
talking about play/social interactions, an observable change in children’s skills, transference of skills and the need for support to refresh learnt lessons over time. Conclusions: The intervention demonstrated preliminary and long-term efficacy in developing the social play skills of children with attention deficit hyperactivity disorder. Further research is required to optimise intervention feasibility and parent involvement prior to conducting a large-scale research. KEY WORDS evidence-based practice, programme evaluation, psycho-social intervention development, research related, social skills.
Introduction The profound social difficulties experienced by children with attention deficit hyperactivity disorder (ADHD) are well-documented to continue into adolescence and adulthood (Bagwell, Molina, Pelham & Hoza, 2001; Barkley, 2006; Nixon, 2001). One profound social difficulty that children with ADHD experience is difficulty playing with peers (Cordier, Bundy, Hocking & Einfeld, 2010a). Social play with peers, which is predominant in middle childhood, is known to support the development of complex pro-social skills such as: peer engagement, social competence, cooperation, problem-solving and communication (Bundy, 2012; Florey & Greene, 2008; Gifford-Smith & Brownell, 2003). Pharmacological interventions successfully alleviate ADHD symptoms in some children, whereas there is limited evidence of their effectiveness for improving social skills. Similarly psycho-social interventions have demonstrated minimal effectiveness (Pelham & Fabiano, 2008). Additionally, the feasibility and social validity of traditional social skills training approaches have been increasingly questioned (Antshel & Barkley, 2008; Pelham & Fabiano, 2008). Explanations for the poor outcomes produced by traditional social skills training approaches include: (i) the removal of children from the natural environments
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where they both develop social skills and experience inter-personal difficulties; (ii) lack of parent involvement; (iii) treatment delivered in group contexts which place too great a demand on children developing new social skills; and (iv) a focus on poor social skills without considering the underlying impairment (Antshel & Barkley, 2008; Antshel & Remer, 2003; Pelham & Fabiano, 2008). Over the past decade, there has been increasing focus on developing evidence-based interventions and supporting families to make evidence-based treatment decisions (Eiraldi, Mautone & Power, 2011; Pelham & Fabiano, 2008). Thus, there is an amplified need for evidence-based psycho-social interventions to successfully address the social difficulties of children with ADHD. Such interventions should: (i) build on previous approaches (Antshel & Barkley, 2008); (ii) undergo rigorous development and testing; (iii) have a strong theoretical base (Craig et al., 2013); and (iv) have evidence of effectiveness, feasibility and appropriateness (i.e. the participants’ perspective of the intervention; Evans, 2003).
Guidelines for developing complex interventions Most non-pharmacological health-care interventions are considered complex due to the presence of several interconnected components. Guidelines have been compiled by the United Kingdom’s (UK) Medical Research Council (MRC) to provide structure for the development of complex interventions (Campbell et al., 2000; Craig et al., 2013; Medical Research Council, 2008). The guidelines have been widely used and act to ensure a comprehensive approach to the development, imple-
Refine pilot
How does it work?
How can it be optimised?
Phase 1
Phase 2
Definitive trial
Does it work in controlled settings?
Phase 3
Long term
Does it work in “real-life” settings?
Effective? Feasible? Appropriate?
Theoretical Phase
Central to the first phase for developing complex interventions is the need to establish a theoretical rationale that demonstrates how the intervention is likely to be effective in addressing the identified need. Thus, a sound theoretical base that is congruent with the
Implementation
Why should this work?
Theoretical phase: Theoretical model of the play-based intervention
Evaluation
Theoretical base
Feasibility
Development
Pilot trial
mentation, evaluation and dissemination of such interventions (Campbell et al., 2000). The UK MRC guidelines emphasise a systematic, phase-based approach to researching complex interventions (Fig. 1) (Campbell et al., 2000). The guidelines emphasise that before conducting a full-scale evaluation, a series of pilot studies may be required to optimise and refine the intervention (Campbell et al., 2007; Craig & Petticrew, 2013). Further, the need to collect data on both outcome measures and perceptions of participants during the early phases of intervention development is emphasised (Campbell et al., 2007; Evans, 2003). Applying the above guidelines, this paper aimed to further the development of a play-based intervention (Wilkes, Cordier, Bundy, Docking & Munro, 2011), addressing previous limitations and strengthening its foundation prior to further clinical trials. The play-based intervention, which is in the early phases of development, aims to improve the social play skills of children with ADHD. Social play has been operationally defined as, ‘play within a social context involving peer-to-peer interactions’. Further development of the intervention is important as interventions targeting the social impairments of children with ADHD have demonstrated minimal effectiveness (Antshel & Barkley, 2008).
Phase 4
FIGURE 1: Continuum approach for developing complex interventions. Adapted from: Campbell et al. (2000); Craig and Petticrew (2013); Evans (2003); Medical Research Council (2008). © 2014 Occupational Therapy Australia
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underlying problem and justifies the components of the intervention and the desired outcome is required (Campbell et al., 2000; Medical Research Council, 2008). The play-based intervention undergoing development is based on a conceptual framework developed by Cordier, Bundy, Hocking and Einfeld (2009). Cordier et al. (2009) identified little research on the social play of children with ADHD. This was surprising, as therapists commonly use play as a medium for assessment and intervention of the social difficulties of children (Barkley, 2006; Cordier et al., 2009). By reviewing literature on both ADHD and play, Cordier et al. (2009) developed a theoretical model, postulating how the characteristics of ADHD influence the play of these children. The ‘model for a play-based intervention for children with ADHD’ was developed on the assumption that play is an important childhood occupation and is the natural context, which facilitates a child’s physical, cognitive, social and emotional development (Bundy, 2012; Florey & Greene, 2008). Foundational to the model is the following definition of play: a transaction between players and the environment that is intrinsically motivated, internally controlled, free of the objective constraints of reality (Neumann, 1971) and requires skills related to framing (giving and responding to verbal/nonverbal cues and maintaining the play frame; Bateson, 1972; Bundy, 2004). Using the Test of Playfulness (ToP; Bundy, 2004), which operationalises the above definition a theoretical model was then constructed and tested. To test the initial theoretical model, the authors compared the play of children with ADHD (n = 112) to that of their typically developing playmates (n = 112) and to a control group of typically developing children (n = 126). In pairs (child with ADHD and their typically developing playmate or two children from the control group), children were instructed to play in a room filled with toys. Results indicated that overall, the social play skills of children with ADHD were significantly lower than those of the typically developing children in the control group. However, interestingly, children with ADHD scored significantly higher or similarly to the control group on some relatively difficult ToP items reflecting social play: skill to initiate, skill to negotiate and extent of social play. However, they scored significantly lower on relatively easier ToP items, such as the skill of: sharing, supporting a playmate and responding to cues. The researchers (Cordier et al., 2010a) concluded that the configuration of difficulties seen in the children with ADHD could be described best as poor inter-personal empathy. Feshbach (1997) described empathy to have both affective and cognitive components. When children are observed playing together, the components of empathy can be seen in 7 ToP items: (i) the ability to discriminate and identify the emotional states of others (ToP item: skill of responding to play cues); (ii) the ability to perspective-take (ToP items: skill of sharing, skill of transitioning between activities and
skill of pretend play); and (iii) the evocation of shared affective response (ToP items: skill of supporting others, intensity of social play with another and skill of social play) (Cordier et al., 2010a). Based on these findings, the researchers revised their initial model of play difficulties in children with ADHD and developed principles to serve as the foundation for a play-based intervention for children with ADHD. The model included the following intervention principles: (i) capturing the intrinsic motivation of children, to increase willingness and prolong engagement (their choice of free-play); (ii) facilitating the development of inter-personal empathy through decentring techniques (video feedback); (iii) including a regular playmate, to promote friendship development; and (iv) active parent involvement, to facilitate generalisation of treatment effects (Cordier et al., 2009).
Phase 1: Pilot trial of the play-based intervention As a next step, Wilkes et al. (2011) applied the key principles from the model, to develop and test a play-based intervention. Early into the pilot phase, we realised the importance of a fifth key principal; therapist modelling. This involved a therapist playing in the playroom with the children to promote cooperative play. In the initial trial, the play-based intervention was therapist-led and involved 14 children with ADHD and their playmates (i.e. n = 14/group). Children attended the seven weekly, clinic-based sessions in pairs (child with ADHD and the invited playmate). Each session was 40-minutes. Sessions involved 20-minutes of video feedback followed by a 20-minute play session with a therapist. A primary therapist worked closely with the children, watching videotaped play interactions from the previous week. Children were shown 3-minutes of video footage containing things they did well and things to improve. The therapist helped the children to discuss what they did well and how it helped them have more fun with their friend. The therapist also facilitated a problem-solving discussion to help the children identify things they needed to remember to change (e.g. playing alone, not watching or listening to another). Acting as a playmate to the pair, the therapist then modelled desired social interactions in the playroom. Concurrently, a second therapist worked with the children’s parents. The second therapist and parents observed sessions through a one-way mirror. The second therapist provided feedback on playroom observations, including interactions between children and the techniques used in the playroom by the primary therapist. The therapist also discussed the application of techniques at home and how parents could provide their child with feedback on their social interactions before, during and after play with peers. The ToP (Bundy, 2004) was used to examine child outcomes in the context of social play with a peer. © 2014 Occupational Therapy Australia
302 Overall playfulness of the children and changes on the seven ToP items which reflect the construct of inter-personal empathy (Cordier et al., 2010a; Feshbach, 1997; Wilkes et al., 2011) were selected as outcomes in this study. The intervention demonstrated efficacy for improving the social play skills of children with ADHD (t = 8.1; P = 0.01; d = 1.5). However, methodological limitations included: lack of follow-up of child outcomes, lack of blinded ratings on the observational outcome measure and lack of participant feedback regarding intervention appropriateness (i.e. impact of the intervention from the participants’ perspective). Therefore, further development was required to test and strengthen the scientific rigour of the initial pilot study.
Phases 1 and 2: Refining the initial pilot trial The purpose of this study was to test and strengthen the scientific rigour of the initial pilot study (Wilkes et al., 2011), ensuring a scientific foundation prior to ongoing testing. Previous pre-test and post-test efficacy findings were rescored by raters who were unaware of the purposes of the study. Specifically, this study aimed to: (i) test if treatment effects were maintained 18months following the intervention; and (ii) explore the appropriateness of the intervention by ascertaining parents’ experience of the intervention. We hypothesised that children’s gains would be maintained 18-month following their involvement in the play-based intervention. The following research question was then used to investigate parents’ experience of the intervention: What were parents’ long-term experiences and perceptions of intervention appropriateness?
Methods Participants Following ethical approval from the University of Sydney’s Human Research Ethics Committee, families of children with ADHD who participated in the playbased intervention 18-month prior (n = 14; Wilkes et al., 2011) were invited to participate in the current study. Due to time constraints (i.e. participation during school term 1, 2012), only 5 of 14 families were available to participate. Recruitment yielded five boys with ADHD. Four mothers and one father also participated. All participants were Caucasian. Additional demographic information about the children and their parents is reported in Table 1. The current participants were compared with the original group on all demographic variables; they differed on only one: inattention. As measured by the Conners Comprehensive Behavior Rating Scale (CCBRS; Conners, 2008), inattention was found to be significantly lower in the current sample of children (Z = 2.03; P = 0.04).
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TABLE 1: Participant demographics
Parents Parent demographic variables Mean age in years (SD) Caregiver’s education: University degree (%) Primary caregiver’s occupation Jobs that do not require tertiary qualifications Jobs that do require tertiary qualifications Child Child demographic variables Mean age in years (SD) Gender: Male ADHD symptomology Hyperactivity symptoms Inattention symptoms Conduct behaviour Oppositional behaviour Generalised anxiety disorder Academic difficulties Social problems ADHD subtypes Predominantly inattentive Predominantly hyperactive/Impulsive Combined subtype Medication taken for ADHD Sibling as playmate
Participants
Playmate
45.4 (7.2)
44.2 (5.0)
60 (%) 80
60 80
20
20
8.9 (1.6) 5 of 5
8.7 (1.7) 4 of 5
73.20† 75.80† 67.40 79.80† 75.40† 72.20† 75.00†
54.60 56.60 53.20 65.00 58.40 54.40 74.00‡
1
–
2 2 4 of 5 4 of 5
– – – –
†Conners Comprehensive Behavior Rating Scales mean scores are above the clinical cut-off (i.e. subscale scores > 70. ‡Playmates scored above the clinical cut-off (> 70) on ‘social problems’ (non ADHD symptom subscale); this profile supports literature that postulates playmates of children with ADHD may mirror the negative behaviours exhibited by the child with ADHD (Cordier, Bundy, Hocking & Einfeld, 2010b).
Children included in the current study had a primary diagnosis of ADHD, without inclusion of other major neurodevelopmental or psychiatric disorders and were between the ages of 6–11 years. The DSM-IV1 and CCBRS (Conners, 2008) were used to confirm the diagnosis of ADHD (i.e. ratings above the clinical cut-off,
1
At the time the study was conducted, the DSM-V had not yet been published.
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T-scores ≥ 70 on the DSM-IV subscales of the CCBRS). Children continued to take any previously prescribed medications at the time of their 18-month follow-up. Parents reported no new medications or therapies had commenced in the last 18 months. Children with ADHD invited a typically developing playmate to participate. To avoid unfamiliar playmates influencing the results in unacceptable ways, the child pairs were regular playmates. For the purposes of this study, a regular playmate was a child (including a peer, cousin, sibling, neighbour) aged 6–11 years who engaged in regular social interactions with the child with ADHD as determined by the parents of the children with ADHD. The pairs were also of a similar age (maximum age difference = 3.1 years; mean difference = 2.1 years; SD = 0.7). Playmates did not have ADHD as defined by the DSM-IV criteria (i.e. scores below the clinic cut-off for all CCBRS subscales) and parents/teachers had not raised concerns about the playmates’ development or behaviour.
Instruments Test of Playfulness The ToP (Bundy, 2004) was used as the primary pre-, post- and follow-up test measure. Using the ToP, children’s overall play skills were investigated in the social context of peer-to-peer play interactions. The ToP is a 29-item observer-rated instrument that is suitable for children aged 6 months to 18 years. Each item is rated on a 4-point scale to reflect extent, intensity or skilfulness. The ToP measures the concept of playfulness as a reflection of four elements: internal control, freedom from unnecessary constraints of reality, intrinsic motivation and framing (i.e. the ability to give and read social cues). The ToP has evidence for excellent inter-rater reliability (data from 96% of raters fit the expectations of the Rasch model); moderate test–retest reliability (e.g. intra-class correlation 0.67 at P < 0.01; Brentnall, Bundy, & Kay, 2008) and construct validity (e.g. data from 93% items and 98% of people fit Rasch expectations; Bundy, Nelson, Metzger & Bingaman, 2001).
Conners Comprehensive Behavior Rating Scales (CCBRS) The CCBRS (Conners, 2008) was used as a screening measure to provide a profile of child symptomology. The CCBRS is a well-established research and clinical measure for assessing symptoms consistent with childhood disorders, including ADHD. The parent-rated questionnaire is suitable to describe children aged 6– 18 years. The CCBRS has good evidence for reliability and validity: Cronbach’s alpha 0.67 to 0.97, 2–4 week test–retest reliability coefficient .56 to .96 (P < 0.001), inter-rater reliability coefficients .50 to .89 (P < 0.001), discriminative validity (mean overall classification accuracy 78% across all forms; Conners, 2008).
Procedure The 18-month follow-up assessment took place over one week and involved both a parent interview and a 30-minute clinic play session. The second author interviewed parents over the phone, before a follow-up visit to the clinic. The follow-up play session was conducted by the first and third authors and involved each playpair (child with ADHD and playmate) playing in a playroom without a therapist. In the follow-up session, the two children were shown the toys around the playroom, video camera and one-way mirror/observation room where adults would be. The playroom was set up with inviting play materials that were selected to promote social interactions and free-play activities between children (Cordier et al., 2009). Toys included: an indoor basketball hoop and balls, a sandbox, dress-ups, play dough, balloons, soft bat and ball games, foam objects, construction and figurine toys, tea-set and small tent. The first or third author reminded each play-pair (child with ADHD and playmate) that they would be filmed while playing without an adult for about 20-minutes. Children were reassured they would get to play with the therapist again after the 20-minutes. Children were again reminded of the playroom rules: (i) try not to hurt each other; (ii) come out of the room if you need to tell an adult something; and (iii) have as much fun as you can. The first or third author and the child’s parents observed the children playing from behind a oneway mirror. The therapist then re-joined the children in the playroom for 10-minutes which was not videotaped.
Ratings of children’s play All sessions were video recorded to allow for scoring of children’s social play skills by one of five trained and calibrated raters who were unaware of the purposes of the study. The pre- and post-video footage from the previously conducted play-based intervention (re-analysed) (Wilkes et al., 2011) and the 18-month follow-up sessions were rated for each child. A total of 15 video recorded sessions were randomised and allocated to one of five calibrated raters. No rater scored more than one tape for any child. Calibration of raters on the ToP involved scoring eight existing videotaped segments and comparing their ratings with hundreds of other raters who had viewed the same videotapes, using Rasch analysis. Data from all five raters yielded goodness-of-fit statistics were within acceptable range (MnSq < 1.4; standardised value ≤ 2; Bond & Fox, 2007), demonstrating their consistency as raters.
Semi-structured interviews Semi-structured interviews were used to ascertain parents’ experiences of the intervention. The second author, who was not closely involved with the families, conducted individual semi-structured interviews at the 18-month follow-up. The parent who was most involved © 2014 Occupational Therapy Australia
304 in the intervention participated. Parents (4 mothers and 1 father) were asked about: their/their child’s experience of the intervention they had participated in 18 months prior and about their child’s social interactions over the previous 18 months. Interviews were between 40 and 60 minutes in length. All interviews were audiorecorded and transcribed verbatim.
Data analysis To attain interval-level scores, ToP raw scores were entered into an existing database containing scores of both children with ADHD and typically developing children (= 378). Data were then analysed using Facets (version 3.70.1; www.winsteps.com/facpass.htm), a Rasch analysis program. Facets-generated person measure scores were entered into IBM SPSS version 19 for further analysis. To examine if child outcomes were maintained 18 months following the intervention (and to re-examine pre- to post-efficacy findings), Wilcoxon signed rank tests for related samples were calculated to compare mean ToP scores. The data included re-analysed preand post-video footage from the original study’s baseline and post-test. The post-test data were then included in the analysis with the 18-month follow-up data. Cohen’s-d values were calculated to measure effect. Given the small sample size, a conservative approach using non-parametric statistics was adopted (Siegal & Castellan, 1988). All significance levels were set at P < 0.05. Cohen’s-d values were interpreted as: small, ≥ 0.20; medium, ≥ 0.50; or large, ≥ 0.80 (Cohen, 1992). To analyse parents’ interview responses, thematic analysis by means of an open and axial coding process was employed (Strauss & Corbin, 1990). Each transcript underwent manual coding whereby texts were separated into discrete parts. Data of similar content were then grouped. These groupings were converged to form sub- and core-themes. Data interpretation was checked using peer review processes (Strauss & Corbin, 1990). The first and fourth authors independently conducted the initial stages of manual coding. Thereafter, both authors compared and reviewed the groupings of themes. Themes were then re-examined and modified until consensus was reached. Sub- and core-themes were then reviewed by all authors.
Results The hypothesis that children would maintain gains 18month after the play-based intervention was supported. Wilcoxon signed rank tests for related samples revealed that there was no significant difference in children’s social play skills between the mean overall 18-month follow-up measure scores and mean overall post-test measure scores (Z = 0.14; P = 0.89 and d = 0.4). Lack of significant results are interpreted to indicate no significant regression 18-month post intervention. © 2014 Occupational Therapy Australia
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TABLE 2: Effect sizes of the intervention for children with ADHD Post-test
18-month follow-up
Mean S7† (range)
Mean S18† (range)
SD
Cohen’s-d ‡
18-month following play-based intervention 73.1 (63.5–85.3) 69.0 (53.1–79.4) 9.8 0.4
Pre-test
Post-test
Mean S1† (range)
Mean S7† (range)
Pre–post play-based intervention 46.1 (31.7–56.5) 73.1 (63.5–85.3)
ES
Small
SD
Cohen’s-d‡
ES
16.6
1.6
Large
†S1 = Session 1 of the intervention; S7 = Session 7 of the intervention; S18 = 18-month baseline following the intervention. ‡Cohen-d effect size (ES) were calculated by: Group (mean post – mean pre-test)/pooled SD for group measure scores (Cohen, 1992). SD, standard deviation.
The re-examination of pre–post efficacy findings revealed that the mean overall post-test scores were significantly higher than the mean overall pre-test scores (Z = 2.02; P = 0.04; d = 1.6) and that effect size was large (i.e. > 0.80; Cohen, 1992). These findings were similar to those previously reported (d = 1.5; Wilkes et al., 2011) (Table 2). Thematic analysis of parents’ interview responses revealed five core-themes: (i) the intervention as an enjoyable/positive experience; (ii) a common language for talking about play and social interactions; (iii) an observable change in children’s play, social, regulation and language skills; (iv) improved relationships resulting from transference of skills to the home and school; and (v) the need for support to refresh and reinforce learnt lessons over time. All participant quotes are presented in “italics” and pseudonyms are used.
Intervention as an enjoyable/positive experience For both parents and children, one important benefit was the positive experience of attending the intervention. Playing/observing play, interacting with therapists and engaging in video self-modelling was an enjoyable and supportive learning experience, “Ben really enjoyed himself! They enjoyed coming, they enjoyed the playtime, they really enjoyed seeing themselves on the DVD [video self-modelling].” “The [therapist] modelling – that worked really well for Ryan, having someone in there [playroom], playing with him and showing him how. I think the DVDs
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were good as well. . .watching it [previous play interactions] and talking about the play.”
Common language for talking about play and social interactions The predominant benefit to parents was “some really useful, common language for talking about play and all the strategies.” “It gives us as parents, ways to support them during socialisation. . .a shared child-appropriate language to talk about it [social interactions] with the kids, in ways they can work their way out of that problem without being destructive, or us having to solve it.” “They learnt little catch phrases [video self-modelling/common language] and learnt to pace themselves more”.
Observable change in children’s play, social, regulation and language skills For children, parents spoke about ongoing observable changes in their child’s skills in the 18-month following the intervention. Parents spoke about changes in their children’s play with peers, “particularly good in the way that it helped them through their play together – that was the real cause of a lot of arguments” and social skills “he’s making his own friendships really well too”. Additionally, parents spoke about observed changes in their child’s self-regulation. “He’s a high energy child. . .so he’s learnt to sort of stop and he thinks”, and language skills “He tended to be more responsive. He started talking more about things that would happen – so he was feeling able to access the language to describe the experience and feelings more.”
Improved relationships resulting from transference of skills to the home and school Parents stated that their children’s newfound skills transferred to the home and school environments, which led to improved sibling relationships and the development of friendships. “Daniel has developed a lot more love for his brother.” “Harrison made some new friends [at school]. . .three good friends, which he didn’t have before. . .he would always play by himself.” It had a big impact and the school noticed it! Ryan’s behaviour improved a lot at school. . .it helped his confidence with other kids, there seemed to be less conflict with other kids in the playground and less of a miss-fit socially. He learnt a lot about how to play and listen to other people – he had some recipes of how to go about it.
Need for support to refresh and reinforce learnt lessons over time The final core-theme reflected a parent identified need for “top-ups” [of the intervention strategies] to support them as they continued to use the intervention strategies over time. Parents recognised their involvement in the intervention as a valued experience, from which
they continued to use the strategies over time. “So that’s why we’ve been playing, to gently steer him to make good choices”. Parents also discussed the continuing nature of their child’s interactional difficulties and the importance of continuing the strategies to help their child. They can use the skills that come out of it [intervention], play is an ongoing issue to work on, not one of these issues that just goes away – you have to keep working on it to get better”. “If they take a bit away, if their language changes a bit and their attitude towards a person, if they’re a bit kinder and more considerate – I’m thrilled! At the end of the day, we’re all here for Daniel.
Parents also identified the need for support and refreshing of material, so they could continue assisting and supporting their child over time, “We just need refreshing. . .to see it and hear it all again. To practice it more and reinforce it at home. . .doing it again and being all refreshed.” “There’s a lot I’ve forgotten. If I read it, I’ll remember it. . .the problem I have - is my husband wasn’t involved. . .reinforcing it. It’s only me and I don’t do it all the time.” “A problem comes up every second week and we need to be on top of it every week. It’s a lot of work!” And into the future, “Next year, they’re [friends] not in the same class. . .and in high school. . .he’ll have to learn the whole thing again. . .so he needs the basics now.”
Discussion The purpose of this study was to further develop the play-based intervention for children with ADHD by building on the foundations of the initial pilot study (Wilkes et al., 2011). Specifically, we conducted an 18month follow-up to investigate if gains in social play skills were maintained over time and to examine parent perceptions of the intervention. We hypothesised that children’s gains from the intervention would be maintained in the long-term. Child outcome data, as measured by the ToP (Bundy, 2004) and as described by parents, indicated that children maintained gains in their social play skills 18-month following participation in the play-based intervention (Z = 0.14; P = 0.89 and d = 0.4). Although the intervention (Wilkes et al., 2011) was intensive and involved two therapists, long-term intervention effectiveness is important. The results are promising, as few psychosocial interventions have evidence of effectiveness (Antshel & Barkley, 2008; Antshel & Remer, 2003; Pelham & Fabiano, 2008). Additionally, ensuring children with ADHD maintain gains in empathy and pro-social skills is essential as these difficulties are known to continue into adolescence and adulthood (Bagwell et al., 2001; Nixon, 2001). In particular, empathy and pro-social skills such as: sharing, cooperating, supporting another, perspective-taking and negotiating are needed for the
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306 development of reciprocal friendships (Bundy, 2012; Florey & Greene, 2008). Having a friend is important as research demonstrates children who overcome social difficulties are more likely to have positive long-term outcomes than those who continue to experience problems with peers (Barkley, 2006; Fabiano et al., 2009). Moreover, in supporting dyadic friendships, a characteristic of this intervention, we expect that participating children may have attained another important benefit – a genuine friend, although that remains to be studied. Consistent with recommendations from recent literature, the inclusion of naturalistic contexts in which social skills are developed (dyadic play with peers and parent involvement) likely contributed to children maintaining gains in the long-term (Antshel & Barkley, 2008; Antshel & Remer, 2003; Cordier et al., 2009; Pelham & Fabiano, 2008). Reasonably, by including parents and peers, it is likely that children were also exposed to and benefited from ongoing supported play opportunities after the intervention has finished. Parents’ interview responses confirmed that the playbased intervention was a positive, enjoyable and beneficial experience for both themselves and their children. Parents further reported that they continued to use the intervention strategies with their child for some time after the intervention and that their child’s newly gained skills transferred to the home and school environments. We postulate parents continued the use of strategies due to their practical and repetitious nature, which could have reinforced target skills and resulted in continued use (O’Neill, Rajendran & Halperin, 2012). Very likely, these factors contributed to the long-term maintenance of the children’s gains. Parents also gained from the intervention; they developed skills to foster positive interactions with their child. In particular, parents discussed that the intervention provided them with a “common language” that served as a basis for problem-solving with their child around social interactions in ways their child responded to. It is hypothesised that this common language: (i) enabled parents to support their child to regulate their emotions and (ii) assisted children to pre-empt the social skills they required in peer-interactions. Promoting positive parent–child interactions is important as parents of children with ADHD often experience high levels of relational frustration, low levels of parenting confidence and the tendency to be critical of their children’s social interactions (Anastopoulos, Guevremont, Shelton & DuPaul, 1992; Mikami, Jack, Emeh & Stephens, 2010). We believe that the support parents received led to: (i) increased social opportunities with their children and (ii) a means to construct positive feedback before, during and after social interactions (Mikami et al., 2010). Parents also spoke about the play, social, language and self-regulation skills their children gained from participation in the intervention. It is likely that the inclusion of peers assisted with the maintenance and © 2014 Occupational Therapy Australia
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generalisation of skills from the clinic to home and school. We found that the inclusion of a known peer in the context of play provided children with ongoing opportunities to develop social skills needed for friendships; including: problem-solving, perspective-taking, supporting, sharing and negotiating skills (GiffordSmith & Brownell, 2003).
Limitations Only 5 of 14 participants attended the 18-month followup. The small, non-randomised sample limits generalisation of results to the broader population of children with ADHD. Further research is required.
Conclusions The play-based intervention, situated in a strong theoretical foundation, has now been shown, preliminarily, to be effective in both the short- and long-term. These findings set the stage for continued development and refinement of the intervention (Campbell et al., 2000; Medical Research Council, 2008). In line with the guidelines for developing complex interventions, further pilot testing is required before a larger-scale randomised trial can be conducted (Campbell et al., 2000, 2007; Craig et al., 2013).
Future research The aim of subsequent pilot trials would be to refine and optimise the intervention (Campbell et al., 2000, 2007; Craig et al., 2013). Specifically, we see the need for a manual for use by parents. A manualised parent component could serve a dual purpose: to promote effective parent involvement and to reduce costs associated with the second therapist. Further, measuring parent–child relationships could add to our understanding of intervention outcomes (Ginsburg, 2007). Such information would be useful for the later phases of intervention development; whereby programme allocation (i.e. mode of intervention delivery, intervention length or design) may be influenced by parent–child relationship variables.
Acknowledgements The authors extend their gratitude to the participating families. The authors also wish to acknowledge the award of the APA from the Australian Government and financial support from the Rotary Club of Mosman.
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