More than child’s play: the potential benefits of play-based interventions for young children with ADHD

Keywords::

• ADHD
• executive functioning
• play
• preschool
• treatment

The phrase ‘play-based interventions’ tends to generate thoughts and images of play therapy. This treatment, which originated with Anna Freud and Melanie Klein, and was subsequently developed by Axline, Landreth and others, uses play as the primary way in which a child expresses him/herself and communicates with the therapist [1]. From this perspective, in the context of a safe therapeutic relationship, during play with the therapist children express their feelings and learn more adaptive strategies to manage their distress and improve their level of functioning [1].

Although play therapy is widely used in clinical settings to treat children’s emotional and behavioral problems, to our knowledge, only one study has investigated the efficacy of play therapy on children’s inattentive and hyperactive/impulsive behavior [2]. Children aged 5–11 years were randomly assigned to either child-centered play therapy or reading mentoring. Following a 16-week intervention, improvements in teacher-rated attention-deficit hyperactivity disorder (ADHD) behaviors were observed, irrespective of the treatment children received [2]. Thus, there are no compelling empirical data to support the use of traditional play therapy for the treatment of ADHD.

Nevertheless, engaging in play serves a critical role in young children’s social, affective and cognitive development [3]. Animal studies have shown the importance of play in both promoting neural development and in ameliorating negative behavioral sequelae of brain insult [4,5]. With respect to ADHD, Panksepp et al. have shown that chronic rough and tumble play in rats with right frontal lesions reduces their activity level [5]. As ADHD is a neurodevelopmental disorder characterized by delayed brain development [6], we suggest that a more ecologically valid use of directed play has the potential to ameliorate many of the difficulties characteristic of children with ADHD and to improve long-term trajectories. Specifically, we propose that rather than playing with the therapist, an important component of treatment should be to facilitate neural and social development through play with parents, siblings and peers.

So how might play be integrated into the treatment of young children with ADHD, particularly given that play therapies emerging from the psychoanalytic model do not appear to be effective for ADHD? Neuropsychological findings indicate that children with ADHD show deficits in a wide variety of executive and nonexecutive functions that are probably linked to their behavioral difficulties [7]. Accordingly, we [8,9] and others [10] have designed games to target skills such as inhibitory control, working memory and motor coordination, or have utilized commonly known children’s games (such as ‘Simon says’ and hopscotch) that require these functions.

Programs should also be cognizant of how children play the games – Vygotsky’s [3] sociocultural theory is central to this conceptualization. He proposed that children are better able to learn complex mental tasks by interacting with more knowledgeable peers and adults. More able partners guide the learning of tasks that children cannot do on their own, but can accomplish with help (the so-called ‘zone of proximal development’). Through a teaching technique known as scaffolding, the adult either pulls back his or her support as the child’s skill level improves, increasing the child’s autonomy, or gradually increases task demands to build skills.

By playing games in the real world with peers, siblings and parents, the social context is not only thought to aid children’s cognitive development, but it is also hypothesized to benefit their social skills. It is through play that children learn skills such as turn-taking, flexibility and compromise, cooperation, and perspective taking [11]. Improvement in these skills is particularly important for children with ADHD, whose symptomatology places them at greater risk of experiencing long-lasting interpersonal difficulties [12].

Furthermore, potential benefits to the parent–child relationship may be a particular advantage of play-based interventions. It is well known that parenting a child with ADHD can be stressful [13], and compared with mothers of typically developing children, mothers of children with ADHD tend to be more negative in their interactions with their children [14]. Furthermore, in this busy world, there are many competing demands for parents’ and children’s time; consequently, the amount of time children spend playing (particularly with their parents) has diminished [15]. By designing an intervention that encourages parents to play directed but fun games with their children, it provides the opportunity for parents to enjoy more positive interactions with their children, which may lead to a shift in the dynamic between parent and child. Apart from being enjoyable, games provide opportunities for parents to set clear rules and place limits around children’s behavior, perhaps leading to an increased sense of parenting efficacy. The transactional nature of parent–child interactions means that as parenting style becomes less harsh, there should be a concomitant improvement in children’s behavior. Although anecdotal, we have found that our play-based cognitive intervention appears to enhance positive interactions and bonding between the parent and child. For example, one mother wrote that her child was, “more patient and feels he has a better handle on his own emotions.” Another parent wrote, “I definitely noticed a change in structure and discipline at home. No more hesitation or punishment.” These findings are consistent with other psychosocial interventions that focus on joint parent–child work. For example, Bratton et al. showed that play therapy was more efficacious when parents were involved in the intervention [1]. Another example is parent–child interaction therapy, which is specifically designed to change parent–child interaction patterns [16].

While we are first and foremost concerned with any intervention’s efficacy, it is also vital that the treatment is palatable and practicable. This is particularly relevant for ADHD where it is unlikely that a short-term psychosocial (or pharmacological) intervention will have an enduring effect on children’s outcomes. It is likely that games will have to be practiced frequently over time to see changes to children’s developmental trajectories. Interventions that are not enjoyable for either the caregiver or the child run the risk of being put out of mind as soon as the active treatment phase is over. Therefore, in order for parents and children to choose to play the games every day, the intervention has to be engaging.

Second, the portability of most games means that they can be played in multiple settings, including at home, school, the car and even while shopping in the supermarket. A carefully equipped laboratory can be a good setting for parents and children to initially learn the games and techniques for scaffolding, engagement and keeping it fun. However, given the diversity of materials that can be used and the possibilities for improvisation, play intervention can be reinforced by caregivers and teachers beyond the laboratory, enabling children to transfer their skills to different settings.

Given the hypothesized requirements and effects of play-based interventions, how do they stand up when we look at the data? Although in its infancy, there is emerging evidence that play-based interventions carried out in a social context are palatable to parents [8,10]; improve preschoolers’ neuropsychological functioning [9,10,17]; and reduce the severity of preschoolers’ inattention and hyperactive/impulsive behaviors, as rated by parents and teachers [8–10]. Importantly, these behavioral changes have been shown to last for months beyond the termination of active treatment [8,9]. In light of these findings, we consider that play-based interventions offer an exciting direction for the development of novel approaches for working with preschoolers with ADHD.

As for further proof of efficacy, randomized controlled trials are certainly needed to determine whether such interventions can serve as a primary treatment for preschoolers with ADHD. Yet, the integration of this approach with other evidence-based treatments should also be explored. What is notable about current evidence-based psychosocial treatments such as parent-management training or contingency management in the classroom is that the therapist works almost exclusively with parents and the teacher, with minimal, if any, contact with the child. That is also commonly the case with pharmacological treatments. Although these treatments show many short-term benefits, such as a reduction in ADHD symptoms, reduced parent stress and improved academic outcomes [18,19], they do not appear to give rise to long-lasting improvement in ADHD symptomatology or its associated impairment [20]. As such, there is a need for more palatable interventions that yield enduring change for children with ADHD. By enhancing neurocognitive development and improving parent–child relations through the use of directed play, we believe that such a goal may be achievable.

Disclaimer

This content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institute of Mental Health.

Financial & competing interests disclosure

This work was supported by grants (R21/R33 MH085898 and R01 MH68286) from the National Institute of Mental Health to J Halperin. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.