Examining the language skills of children with ADHD following a play-based intervention

Abstract

Communication and play skills are important aspects of development yet are largely uncharted in children with attention deficit hyperactivity disorder (ADHD). This exploratory study examined whether changes in pragmatic skills and problem-solving skills were observed in children with ADHD pre- and post-participation in a play-based intervention conducted by occupational therapists and speech-language pathologists. The study also investigated whether the presence of language difficulties affected the children’s play outcomes. Fourteen children with ADHD (5;0–10;7 years) participated in a 7-week, pilot intervention to address play and social skill deficits. Pre- and post-intervention testing included: (a) the assessment of play and problem-solving skills via standardized testing, and (b) pragmatic skills via parent report. The children’s language skills were also screened and compared with their play scores. Play skills significantly improved post-intervention. No significant differences were observed for pragmatic skills while prediction skills, an aspect of problem-solving, significantly improved pre- and post-play-based intervention. Fifty percent of children failed the language screener, yet separate paired t-tests identified significant play improvements irrespective of the presence or absence of language difficulty. Two independent t-tests revealed significant differences in play scores between these groups at pre- but not post-intervention.

While play and predicting skills significantly improved post-play-based intervention, other aspects of problem-solving and pragmatics did not. Reasons for the lack of change in these areas are discussed. The presence of language difficulties did not appear to affect the play outcomes of children with ADHD following a play-based intervention. A larger scale experimental trial investigating the play and language skills of children with ADHD is warranted, as is future collaborative research between occupational therapists and speech-language pathologists in the assessment and management of children with ADHD.

Keywords

ADHD language play-based intervention pragmatics problem-solving social skills

I Introduction

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by developmentally inappropriate levels of inattention, impulsivity and hyperactivity that cause impairment in day-to-day life (American Psychiatric Association, 2000). Most children with ADHD have serious social and play deficits (Barkley, 2006; Cordier et al., 2010). As a result, they are commonly rejected by peers and have few friends (Mrug et al., 2001). Interpersonal difficulties and poor peer relationships have been found to be predictive of negative long-term outcomes, such as antisocial behavior and mental health problems (Mrug et al., 2001). These disquieting consequences underscore the need for early interventions to fundamentally shift this trajectory at its earliest point. This article examines the pragmatic and problem-solving outcomes of the children with ADHD who participated in a play-based intervention aimed at improving their play and social skills (Wilkes et al., 2011).

1 The play of children with ADHD

For the purposes of this study, play was defined as a transaction between the individual and the environment that is intrinsically motivated, internally controlled, free of many of the constraints of objective reality and framing-related skills (reading and responding to cues; Skard and Bundy, 2008). Play manifests in children as playfulness (i.e. the disposition to play; Bundy, 2004). Most authors have written about play and playfulness as though they are synonymous (Skard and Bundy, 2008). Whilst children often play by themselves, certain characteristics of play can only be observed when the play transaction occurs between playmates (e.g. sharing and turn-taking), referred to here as social play.

Given the importance of play to social development, surprisingly little published research exists regarding the impact of ADHD on play. The limited research suggests that children with ADHD are less playful (Leipold and Bundy, 2000) and have difficulties with the social dimensions of play (Cordier et al., 2009). Specifically, children with ADHD experience difficulty supporting the play of others, responding to others’ play cues, sharing, and interacting in a cooperative manner. This is indicative of previously established characteristics, which include being preoccupied with having their own needs met and difficulty expressing interpersonal empathy, which in turn impacts their ability to develop meaningful friendships (Barkley, 2006; Cordier et al., 2010; Purdie et al., 2002).

2 Play-based intervention

A pilot play-based intervention was conducted by a pair of occupational therapists (OTs) and consisted of seven 40-minute weekly sessions involving both a child with ADHD and a typically developing (TD) regular playmate (aged between 5 and 11 years) (Wilkes et al., 2011). Each child with ADHD invited a regular TD playmate of a similar age to participate in the intervention. Each play-pair was allocated a primary therapist to promote a positive therapist–child relationship. The primary therapist used video feedback techniques by discussing the segments of the play-pair’s past performance with them. The therapist then used video feed-forward techniques by facilitating a problem-solving discussion with the children, helping them to develop strategies to pre-empt the changes required for future social skill development to occur. While playing, the therapist modelled prosocial behaviours (e.g. sharing, supporting, responding) by engaging in mutually enjoyable social play and by encouraging joint pretend play. Concurrently, the second therapist worked closely with the child’s parents and provided education, support, training and feedback. Parents observed all playroom and feedback/feed-forward sessions through a one-way mirror, completed weekly play tasks and reviewed their weekly take-home copy of the feedback/feed-forward footage with their child before the next session.

Results of the pilot study revealed significant improvements in social play skills as measured by the Test of Playfulness (ToP: Bundy, 2004) for both children with ADHD and their TD peers (Wilkes et al., 2011). However, despite improvements in social play, it is unknown whether the children’s pragmatic and problem-solving skills improved or not. This is important for two reasons. First, language is central to play (Weiss and Paul, 2010); and, second, pragmatics and problem-solving skills are not only poor in children with ADHD, they could also improve following play-based intervention. Each of these issues will now be considered in turn.

3 Play and language

Play is the most natural context for learning language. Children learn to interact and build the foundations for pragmatic skills used for conversation, such as turn-taking; share concepts; and verbalize thoughts and ideas through play (Cordier et al., 2009; Levy, 1984). In play, children are given the opportunity to learn from each other, express themselves, cope with their emotions and connect concrete and abstract thinking (Levy, 1984). Children also use language to organize pretend play, develop and practise skills for problem-solving in a variety of situations, and explore interactions (Weiss and Paul, 2010).

a Pragmatics

Pragmatics refers to the appropriate use of language and social skills, including timing and quantity of interaction within a given context (Bruce et al., 2006). Children with ADHD are known to have pragmatic deficits (Geurts and Embrechts, 2008). The use of standardized questionnaires (e.g. the Children’s Communication Checklist, 2nd edition, or CCC-2; Bishop, 2003) has identified several pragmatic problems relative to their TD peers: difficulty with identifying facial expressions and perspective-taking, and poor understanding of emotion (Geurts and Embrechts, 2008). Standardized testing has also revealed pragmatic difficulties, such as the inability to select language that is appropriate to social situations, difficulties using contextual cues in judgments of emotion, avoiding tasks, and frequent use of tangential information during conversations relative to TD children (Mathers, 2006). Given the frequently reported presence of pragmatic difficulties, it is therefore no surprise that children with ADHD have many social skills challenges; skills necessary for successful play (Mrug et al., 2001).

b Problem-solving skills

Problem-solving skills are characterized by the ability to make quick and efficient decisions in order to overcome a problem (Borg, 2009), and are important for successful play interactions. Children with ADHD exhibit poor problem-solving skills compared to TD peers (Sibley et al., 2010). Overall, children with ADHD devise fewer solutions to problems. This could, in part, be explained by poor awareness of problem-solving strategies and therefore decreased likelihood that they will spontaneously utilize appropriate strategies when faced with problems (Hamlett et al., 1987). These children also show difficulty describing strategies for problem-solving to others (Hamlett et al., 1987). Moreover, they appear to struggle with predicting the outcome of situations and the responses of others, resulting in their difficulty with formulating socially appropriate responses when faced with challenging situations (Mrug et al., 2001).

c Pragmatic and problem-solving skills during play-based intervention

As verbal problem-solving and pragmatics skills are frequently used during play, it is possible that these skills may have changed during the Wilkes et al. (2011) play-based intervention. For example, both therapist modelling during free-play, as well as self modelling during video feed-forward and feedback sessions, utilized therapeutic social discourse and meta-cognitive thinking strategies relating to problem-solving and prediction. By reviewing edited video footage of themselves and their playmates from the previous session, children reflected on their own performance (video feedback) and problem-solved aspects within the play that worked well or interrupted the play, thus focusing on their perspective-taking and problem-solving skills (LeBlanc and Coates, 2003). Further, by pre-empting the changes required in order to achieve future skill development (video feed-forward), their predictive skills were targeted (Dowrick, 1999). In addition, given the pragmatics deficits in children with ADHD (Geurts and Embrechts, 2008) and that successful play utilizes pragmatic skills such as being responsive to others, reading non-verbal cues and emotional reactions, and anticipating the effects of their own actions (Brinton and Fujiki, 2006), it is also possible that the play-based intervention could impact upon their pragmatic abilities. Pragmatic skills were addressed by the therapist during each video-feedback session of the play-based intervention and modelled during the play sessions by the primary therapist. Parents were also counselled by the secondary therapist as to how to encourage their children to develop these skills.

d Language impairment and play skills

One final consideration is the potential for an interaction between the existence of language impairment and its possible impact on the play skills of children with ADHD. Approximately 45% of children with ADHD present with language impairment (LI); the nature of LI observed in children with ADHD is heterogeneous (Cohen et al., 2000; Tirosh and Cohen, 1998). The high co-morbidity observed between ADHD and LI in the existing literature (e.g. Bruce et al., 2006) would suggest that the presence of LI in children with ADHD may affect play outcome following participation in a play-based intervention (Tirosh and Cohen, 1998). Yet despite the high prevalence of LI and play deficits in children with ADHD, there is no extant research specifically investigating the potential impact that language impairment could have on the play of children with ADHD, nor the association between the two.

4 Aims of the current study

The current study aims to address the following questions:

Do parent-reported pragmatic skills of children with ADHD improve following the play-based intervention?

Do the problem-solving skills of children with ADHD improve following the play-based intervention?

Do the children with ADHD who participated in this play-based intervention present with language difficulties and if so, do these difficulties affect play outcome?

II Method

1 Participants

Once ethical approval from The University of Sydney’s Human Research Ethics Committee was received, children with ADHD were recruited from local paediatric services, primary schools and through a print and radio media release. Criteria for inclusion in the play-based intervention included: a formal and unambiguous diagnosis of ADHD made by a paediatrician using accepted diagnosis protocol (i.e. criteria using the DSM-IV: TR), or Diagnostic and Statistical Manual of Mental Disorders. 4th edition, (Text Revision); American Psychiatric Association, 2000) confirmed via the Conners’ Rating Scale, 3rd edition (Conners, 2008) and the Child Behavior Checklist (Achenbach and Rescorla, 2001). Exclusion criteria included: existing major developmental or psychiatric disorders such as autism spectrum disorder (ASD), intellectual disability, or cerebral palsy. Children with co-morbid conditions such as oppositional defiance disorder (ODD) were not excluded. Children were not excluded if required to take medication throughout the study, and parents were encouraged to provide medication on a stable basis to prevent this variable confounding the data. Recruitment yielded 14 children with ADHD aged between 5;0 and 10;7, consisting of 10 males and 4 females with an average age of 7.6 years. This age range was selected as the nature of the intervention (e.g. emphasizing pretend play; Stagnitti, 2009) was deemed appropriate to their play needs. Eight of the 14 children used medication for ADHD. The demographics of participants are presented in Table 1.

Table 1.

Participant demographics.

Variables	ADHD	Playmates
Mean age: SD (years)	7.6 (1.6)	7.3 (1.6)
Gender: percentage (n):
Male^*	71.4 (10)	57.1 (8)
Female	28.6 (4)	42.9 (6)
Ethnicity: percentage (n):
Caucasian	64.3 (9)	57.1 (8)
Asian	21.4 (3)	28.6 (4)
Other ethnicities	14.3 (2)	14.3 (2)
Primary caregiver’s highest level of education: percentage (n):
Completed high school	14.3 (2)	21.4 (3)
Tertiary qualifications: Diploma/certificate	14.3 (2)	14.3 (2)
Tertiary qualifications: University degree	71.4 (10)	64.3 (9)
Primary caregiver’s occupation: percentage (n)
Jobs that do not require tertiary qualifications	57.1 (8)	64.3 (9)
Jobs that do require tertiary qualifications	42.9 (6)	35.7 (5)

Notes. *Ratio 1:3, this is a close approximation to the 1:5 ratio of girls to boys diagnosed with ADHD as reported in the literature (American Psychiatric Association, 2000).

2 Materials and procedures

a Screening for language difficulties

The Clinical Evaluation of Language Fundamentals, 4th edition: Screening Test (Semel et al., 2004) (CELF-4: Screener) was administered. The use of a screening test was in accordance with Cohen et al. (2000) and Hill (2000) who recommend an initial language screening procedure as a first stage of investigating the presence or absence of LI in children with ADHD. Given that this was an exploratory study, we adopted the same rationale. The decision to use a language screener in the present study also meant that children could only be identified as at-risk for language difficulties (LD) and would require further clinical assessment to confirm the presence of a language impairment. The language screener was completed before session 1 of the play-based intervention and administered by a speech-language pathologist (SLP). The CELF-4: Screener examines structural language abilities in the domains of syntax and morphology (such as regular and irregular verb formation, following instructions, semantic relations and sentence repetition). For children older than 8 years, the screener also examines question formation and semantic (word knowledge) relations.

b Pre- and post-intervention measures of play, pragmatics and problem-solving skills

The children’s play skills were assessed by an Occupational Therapist (OT) using the Test of Playfulness (ToP: Bundy, 2004). The ToP is a 30-item observer rated instrument that can be administered to any individual between the ages of 6 months and 18 years and was designed to measure play across age and diagnostic categories. It measures the concept of playfulness as a reflection of the combined presence of four elements contributing to a single (uni-dimensional) construct of playfulness: perception of control, freedom from constraints of reality, source of motivation, and ability to give and read social cues. From this conceptual framework, and because it does not measure developmentally sensitive skills (e.g. how well they manipulate a toy), the ToP accommodates developmental differences across age categories (Bundy, 2004). Each item is rated on a 4-point (0–3) scale. Scores reflect either extent (proportion of time), intensity (degree of presence), or skilfulness (ease of performance). The ToP has evidence for excellent inter-rater reliability (data from 96% of raters fit the expectations of the Rasch model), construct validity (e.g. data from 93% items and 98% of people fit Rasch expectations), and moderate test–retest reliability (e.g. intraclass correlation 0.67 at p < .01; Bundy et al., 2001). All play sessions were video recorded for detailed analysis after observation using the ToP.

CCC-2 (Bishop, 2003) is a parent/teacher report questionnaire measuring the communication and pragmatic skills of children. It contains 10 subscales (see Table 2). Two composite scores can be calculated: the General Communication Composite (GCC: children who are likely to have significant structural communication difficulties), and the Social Interaction Deviance Composite (SIDC: children who present with disproportionate difficulties with pragmatics skills compared to other aspects of language). The internal consistency (alpha) of the CCC-2 ranges from .66 to .80 (see Bishop, 2003). Australian normative data is only available for children who are six, nine or 12 years of age. To cover our age range of children, we therefore utilized the UK normative data.

Table 2.

Parent-rated pragmatic skills pre- and post-intervention.

CCC-2 subtests and composites	Pre-intervention		Post-intervention
	Mean percentile rank	Standard deviation	Mean percentilerank	Standard deviation
Speech	21.2	24.5	31.1	23.9
Syntax	22.0	26.2	20.4	25.1
Semantics	10.2	21.3	13.2	20.7
Coherence	15.0	28.3	19.4	16.4
Inappropriate initiation	14.7	12.1	28.2	27.6
Stereotyped language	23.8	19.7	32.1	28.1
Use of context	9.1	14.5	15.6	17.2
Nonverbal communication	13.2	12.8	21.9	27.5
Social relations	5.4	4.2	7.3	11.9
Interests	15.8	16.1	20.4	17.4
GCC	7.9	13.9	11.0	7.3
SIDC	−0.7	10.9	−1.0	10.9

Note. CCC-2 = Children’s Communication Checklist, 2nd edition (CCC-2; Bishop, 2003). CCC-2 data was analysed for 9 children; GCC = General Communication Composite, SIDC = Social Interaction Deviance Composite.

The children’s problem-solving skills were assessed via the Test of Problem-Solving, 3rd edition (TOPS-3: Bowers et al., 2005), a test commonly used in Australia because there is no Australian standardized alternative. This was administered pre- and post-play-based intervention by either a certified, practising SLP or by a trained SLP student under the supervision of a certified practising SLP. The TOPS-3 measures critical thinking skills and problem-solving in children aged 6–12 and has been shown to be clinically useful and valid (McGee et al., 2009). Children were asked to look at pictures and verbally respond to questions falling into the 6 subtests (see Table 3).

Table 3.

Problem-solving skills pre- and post-intervention: TOPS-3 subtests.

Subtests	Pre-intervention		Post-intervention		t-test
	Mean percentile rank	Standard deviation	Mean percentile rank	Standard deviation	t-value	p-value	d-value
Making inferences	31.64	26.67	34.82	26.00	−.473	.646	.14
Sequencing	32.36	38.53	34.45	27.90	−.474	.646	.14
Negative questions	45.64	29.98	47.27	20.96	−.243	.813	.07
Problem-solving	38.36	27.25	43.27	26.04	−.780	.454	.24
Predicting	25.91	21.40	39.09	29.47	−2.510	.031*	.76
Determining causes	41.18	31.82	35.27	28.55	.728	.483	.22
Total TOPS-3	34.00	28.54	36.45	25.96	−.669	.519	.20

Note. TOPS-3: Test of Problem-Solving, 3rd edition (Bowers et al., 2005); TOPS-3 data was analysed for 11 children. *p < .05.

c Play-based intervention

The play-based intervention used by Wilkes et al. (2011) and described in the introduction was implemented. Figure 1 presents the structure of the intervention and when pre- and post-intervention assessment data was collected, relative to the play-based intervention.

Figure 1.

Overview of procedures relative to the intervention structure.

3 Data analysis

a CELF-4: Screener

To investigate whether LD had affected the children’s play outcome, the children were subdivided into two groups based on whether they failed to reach criterion for their chronological age (labelled as ADHD+LD or ADHD–LD). Not reaching criterion for their chronological age indicates that these children were at least 1 SD below the mean.

b Test of Playfulness

To attain interval level scores for each participant, ToP raw scores were entered into an existing data base containing scores of children with ADHD and typically developing children (n = 378). The data were then subjected to Rasch analysis using the Winsteps program (version 3.70.0.2; Linacre, 2007).

The resulting measure scores of the sample were then entered into the Statistical Package for the Social Sciences (SPSS: Nie and Hull, 2006) and two tailed t-tests for dependent samples were calculated to compare pre- and post-test mean ToP scores from Sessions 1 and 7. All significance levels were set at p < 0.05. A non-parametric one-sample Kolmogorov–Smirnov test was used to compare the observed cumulative distribution with the expected null hypothesis distribution. The goodness-of-fit tests if observations could reasonably have come from the specified distribution; thus parametric testing was deemed appropriate.

c Pragmatics and problem-solving skills

Visual inspection and one-sample Kolmogorov–Smirnov tests via SPSS revealed normal distribution of the pragmatic and problem-solving data. Where appropriate, Cohen’s d values were calculated to examine effect size with 0.20 described as a small effect size, 0.50 as medium, and 0.80 as large (Kotrlik and Williams, 2003).

III Results

1 Pragmatic outcomes pre- and post-play-based intervention

Two composite scores on the CCC-2 were calculated at pre- and post-intervention: the General Communication Composite (GCC) and the Social Interaction Deviance Composite (SIDC). Data from 1 participant (pre-intervention) and 2 participants (post-intervention) were excluded due to invalid data set responses. In addition, two parents did not complete the CCC-2. A total of 9 out of 14 profiles were subsequently included for analysis. Table 2 identifies the children’s average percentile rank performance on the CCC-2 for each subtest, and the two composite scales (GCC and SIDC) before and after the play-based intervention. Paired sample t-tests (two tailed) were not significant (GCC: t ₍₈₎ = −0.659, p = 0.528, d = 0.22; SIDC: t ₍₈₎ = −1.755, p = 0.117, d = 0.05). Individual subtests are reported in Table 2. We also examined five individual subscales of the CCC-2 previously reported to reflect pragmatic aspects of language (subscales D-H; e.g. Geurts and Embrechts, 2008). These also were non-significant pre- and post-play-based intervention; Coherence: t ₍₈₎ = −0.724, p = 0.490, d = 0.24, Inappropriate Initiation: t ₍₈₎ = −1.982, p = 0.082, d = 0.66, Stereotyped Language: t ₍₈₎ = −1.112, p = 0.298, d = 0.37, Use of Context: t ₍₈₎ = −0.819, p = 0.437, d = 0.27, Non-verbal Communication: t ₍₈₎ = −0.809, p = 0.442, d = 0.27. In summary, based on parent report, pragmatic skills did not improve between the pre- and post-play-based intervention assessments.

2 Problem-solving skills

Table 3 reports the children’s average percentile rank performance on the TOPS-3 before and after the play-based intervention, as well as results for the paired t-tests. Data was subjected to a paired samples two tailed t-test on the total TOPS-3 score and the subtests of the TOPS-3. Data for 3 children were excluded due to age restrictions on administration. Results revealed no significant differences between the total TOPS-3 pre- and post-scores (t ₍₁₀₎ = −0.669, p = 0.519, d = 0.20). No significant differences were observed for the TOPS-3 subtests; Making Inferences, Sequencing, Negative Questions, Problem-Solving or Determining Causes, while significant improvements were found from pre- and post-intervention for Predicting (t ₍₁₀₎ = −2.150, p = 0.031, d = 0.76). Therefore prediction is the only aspect of problem-solving skills that improved significantly between the pre- and post-play-based intervention assessments.

3 Language difficulties and play outcomes

Table 4 identifies the children’s performance on the CELF-4: Screener. Seven of the 14 children with ADHD failed to reach criterion for their chronological age. Compared to the reported means and standard deviation (SD) by age on the CELF-4 Screening Test, the raw scores of the 7 children who failed the screener in the current study were between −1 and −3 SDs below the mean. While not wholly indicative of language impairment, the finding suggests that 50% of our sample presented with language difficulties (LD).

Table 4.

ADHD sub-groups according to language screening.

Child	CELF-4 criterion score	Child score
ADHD+LD:
04	18	11
05	10	8
08	14	10
09	18	9
15	10	4
16	16	10
18	16	14
ADHD–LD:
02	18	21
07	14	21
11	17	17
12	16	16
14	10	23
17	18	21
19	18	26

Note. LD = language difficulties, CELF-4 = Clinical Evaluation of Language Fundamentals, 4th edition, Screening Test (Semel et al., 2004).

Table 5 identifies the mean total ToP score at pre- and post-intervention for both subgroups, together with the results of separate paired t-tests. Both subgroups of children significantly improved from pre- to post-intervention (ADHD+LD; t ₍₆₎ = 5.05, p = 0.002, d = 1.91; ADHD–LD; t ₍₆₎ = 4.08, p = 0.007, d = 1.54). To investigate whether there were any between group ToP differences before and after intervention, two independent t-tests were conducted. Children in the ADHD+LD subgroup were significantly poorer at play before the commencement of the play-based intervention relative to the ADHD–LD subgroup (ADHD+LD; pre-intervention mean = 38.4, SD = 7.1, ADHD–LD; pre-intervention mean = 52.3, SD = 7.5, t ₍₁₂₎ = 3.56, p = 0.004, d = 1.91). This difference was not maintained at post-intervention when no significant difference between groups was observed on the ToP (ADHD+LD; post-intervention mean = 59.8, SD = 6.4, ADHD–LD; post-intervention mean = 66.9, SD = 10.1, t ₍₁₂₎ = 1.56, p = 0.144, d = 0.84). In summary, for within-group comparisons, play skills of both groups, with and without LD’s, improved significantly post-intervention. For between-group comparisons, significant differences in play pre-intervention were not maintained post-intervention.

Table 5.

Results for paired and independent t-tests comparing pre- and post-ToP scores based on language difficulties sub-groups.

Comparing within groups:
Sub-group	Pre-ToP		Post-ToP		t-value	p-value	d-value
Sub-group	Mean	Standard deviation	Mean	Standard deviation	t-value	p-value	d-value
ADHD+LD	38.4	7.1	59.8	6.4	5.05	.002	1.91
ADHD–LD	52.3	7.5	66.9	10.1	4.08	.007	1.54
Comparing between groups:
	ADHD+LD		ADHD–LD		t-value	p-value	d-value
	Mean	Standard deviation	Mean	Standard deviation	t-value	p-value	d-value
Pre-ToP	38.4	7.1	52.3	7.5	3.56	.004	1.91
Post-ToP	59.8	6.4	66.9	10.1	1.56	.144	.84

Note. LD = language difficulties, ToP = Test of Playfulness (Bundy, 2004).

IV Discussion

This exploratory study examined the pragmatic and problem-solving skills of children with ADHD following a play-based intervention. In addition, we investigated the presence of language difficulties in children with ADHD and whether their language status affected play outcome. Overall group data revealed no significant difference for pragmatics pre- and post-intervention, while only one problem-solving measure (predicting skills) significantly improved between pre- and post-intervention assessment. Language screening within this study identified that 50% of the children had language difficulties. All children significantly improved with regards to their play skills between pre- and post-intervention assessment. Further, there were no significant differences in play skills between the children when they were subdivided into two groups, based on whether or not they passed a language screening test.

1 ADHD and pragmatic skills

While significant improvements in play skills were found following the play-based intervention, the children’s pragmatic skills, as measured by the CCC-2, did not significantly improve. This can be interpreted in two ways. First, the CCC-2 is a parent questionnaire that asks parents to rate their child’s pragmatic skills across contexts and across interactants beyond the play-based intervention environment. It is therefore possible that no treatment effects were observed for pragmatic skills because the play-based intervention did not generalize beyond the specific child dyad used in the treatment and that this assessment may be too broad in scope. Alternatively, pragmatic skills may have improved if parents were asked to rate their child’s pragmatic skills within the specific interactions observed between their child and their playmate, an investigation reported in Cordier et al. (2013).

2 ADHD and problem-solving

Results from the TOPS-3 revealed that the children’s prediction skills significantly improved from pre- to post-intervention, however, neither the total TOPS-3 score, nor the other subtests of the TOPS-3, significantly differed pre- and post-intervention. While the lack of overall significant findings could be related to poor statistical power, the significant improvements in prediction skills may be due to the explicit therapeutic discourse targeting skills of prediction. For example, the questions relating to the prediction subtest of the TOPS-3 required a child to predict the outcome of a particular social situation (e.g. ‘What might happen if you break something in a grocery store?’; Bowers et al., 2005). This format of questioning is similar to that used in the feedback/feed-forward sessions of the play-based intervention, where children were asked to combine problem-solving skills and foresight to predict the outcome of social situations (e.g. ‘What might happen if you don’t play together and cooperate?’). This finding suggests that explicit therapeutic language within a play-based intervention may facilitate improvements in problem-solving skills. However, our language screening procedure was not sufficient to identify whether any of the children specifically presented with significant syntactic comprehension delays, a factor that could impact their performance on the TOPS and their ability to understand the language used in the feedback/feed-forward sessions. Post-hoc inspection of the TOPS data, based on whether the children passed or failed the language screener, identified that it was mostly the children without language difficulties that improved on the prediction subtest of the TOPS. In addition, the ADHD+LD subgroup performed more poorly on the overall TOPS total score. This suggests that language difficulties can negatively impact verbal problem-solving skills and that the play-based intervention may need further adaptation to better accommodate the needs of children with ADHD and co-morbid language difficulties, specifically in relation to verbally mediated problem-solving skills. It should also be noted that these implications are based on data from 11 children who completed the TOPS pre- and post-intervention, 5 of whom had ADHD+LD.

3 ADHD, play and language difficulties

The results of the current study found that both children with ADHD with and without co-morbid language difficulties significantly improved their play skills from pre- to post-play-based intervention as measured by the ToP. Furthermore, children with ADHD+LD presented with significantly poorer play skills relative to children with ADHD–LD at pre-intervention. However the significant difference between the subgroups was not maintained post-intervention. This suggests that the play-based intervention was effective in improving the play skills of children with ADHD+LD to the extent that there were no longer significant differences compared with the ADHD–LD subgroup. Moreover, this finding suggests that language difficulties may not affect the play outcome of children with ADHD. However, this interpretation must be cautiously received. We determined language difficulties based on the CELF-4: Screener, which by and large examines aspects of structural language performance and not pragmatic skills. It is possible that pragmatic skills may be more interrelated with play skills than structural aspects of language.

An additional comment regarding the use of a language screener is warranted. While it is recommended in the literature (e.g. Hill, 2000), language screeners are designed to deduce the need for further clinical language assessment and are not recommended for use in isolation as diagnostic tools. Even though we cannot identify these children as language impaired, the current findings also suggest that clinical language assessment for all children with ADHD may be clinically warranted (Semel et al., 2004).

4 Limitations and future directions

The findings of this article are based on a small intervention study, characterized by a small sample size of children aged between 5–10 years. The small sample size did not allow us to investigate age- and medication-related trends. It should be noted that while we were able to account for the children’s age range by converting raw scores to percentiles on the language standardized tests, we did so out of necessity, knowing that their standardization was conducted with children not from Australia. A call for further Australian standardization of norm-referenced pragmatic and problem-solving assessments is clearly needed. The lack of overall significant change in language outcomes may also be due to the current therapy dosage, meaning that it is possible that the therapy dosage for the play-based intervention may improve play skills but may not have been of sufficient duration or frequency for language change.

Future studies investigating the language skills of children with ADHD and their language outcomes pre- and post-play-based intervention requires an intervention trial involving randomization and a larger sample size. In addition, the use of a control group where a TD playmate and a child with ADHD engage in free-play, without intervention, could enable comparison of language and play improvements due to intervention versus natural developmental progression. A control group might also incorporate TD dyads. Future play-based intervention may also explore the dosage of explicit language scripting of therapeutic dialogue that targets problem-solving and pragmatic skills of children with ADHD. Publishing these exploratory findings may assist future researchers in designing and testing alternative language outcomes that offer naturalistic observation and assessment of pragmatic and problem-solving skills.

Play-based intervention has the potential for a collaborative relationship between OTs and SLPs who work with children with ADHD. For instance, apart from diagnostic language assessment, SLPs could also have a role in training and supporting OTs in maximizing verbal interactions during play that take into account the child’s language strengths and weaknesses. This collaboration would support previous research findings that suggest joint interventions may be clinically indicated for this population (Purdie et al., 2002). Further investigation to maximize the clinical application of this intervention in both occupational therapy and speech language pathology fields is needed so that both play and language deficits can be addressed in children with ADHD.

Footnotes

Acknowledgements

The authors wish to extend their gratitude to the participants and their families who participated in the research and Dee Why Rotary Club for providing funding support and to Janine McGloin for providing research assistance.

Declaration of conflicting interests

The authors attest that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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