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Empathy in the Play of Children With
Attention Decit Hyperactivity Disorder
Reinie Cordier, Anita Bundy, Clare Hocking, Stewart Einfeld
key words: playfulness, decentering, social problems
ABSTRACT
Many children with attention deficit hyperactivity disorder (ADHD) have serious social and
peer difficulties that can lead to adverse outcomes in adolescence and adulthood. Play provides a
natural context to explore those interactional problems. This study aimed to examine the similari-
ties and differences in play behavior of children as having ADHD and typically developing chil-
dren. Participants were children (aged 5 to 11 years) diagnosed as having ADHD (n = 112) and
typically developing peers (n = 126) who were matched based on age, ethnicity, and gender. The
Test of Playfulness (ToP) was used to measure play. Children with ADHD performed similarly
to typically developing peers on ToP items that related most directly to the primary symptoms
of ADHD but scored significantly lower on several ToP social items; however, they also scored
higher on one difficult social item and no differently on two others, suggesting that the problems
may be developmentally inappropriate lack of empathy rather than simply poor social skills.
Reinie Cordier, BSocSc Hons (Clin Psych), MoccTher, is PhD Candidate, and Anita Bundy, ScD, OTR, FAOTA, is Chair of
Occupation and Leisure Sciences, Faculty of Health Sciences, The University of Sydney, Sydney, Australia. Clare Hocking,
PhD, MHSc(OT), is Associate Professor, School of Rehabilitation and Occupation Studies, Auckland University of Technology,
Auckland, New Zealand. Stewart Einfeld, MD, DCH, FRANZCP, is Chair of Mental Health, Faculty of Health Sciences, and Senior
Scientist, Brain and Mind Research Institute, The University of Sydney, Sydney, Australia.
Originally submitted September 10, 2008. Accepted for publication February 18, 2009. Posted online May 25, 2009.
Address correspondence to Anita Bundy at [email protected].
doi: 10.3928/15394492-20090518-02
A
ttention deficit hyperactivity disorder (ADHD)
is characterized by developmentally inappro-
priate levels of inattention, impulsivity, and
hyperactivity that cause impairment in day-to-day
life. ADHD is associated with a range of behavioral
problems (American Psychiatric Association, 2000).
Many children with ADHD have serious social dif-
culties that may continue throughout adolescence
and adulthood (Barkley, 2006a; Schachar, 1991; Wood,
1995). Peer rejection and few friends are predictive
of adverse outcomes in adolescence and adulthood.
These may include comorbid psychiatric disorders,
school drop-out, development of externalizing be-
haviors, and antisocial behavior, which in turn may
lead to adjustment problems and difculties in adult
relationships (Crick & Dodge, 1994; Erdley & Asher,
1999; Hoza, Mrug, Pelham, Greiner, & Gnagy, 2003;
Ollendick, Weist, Bolden, & Green, 1992).
Currently, treatment outcomes for children with
ADHD are often less than satisfactory. Despite medi-
cation, which is the most common treatment, many
children continue to experience social and peer re-
lationship problems (Hechtman et al., 2005; MTA
Cooperative Group, 1999, 2004). Children from the
Multimodal Treatment Study of ADHD were found
to remain signicantly impaired in their peer rela-
tionships despite evidence of improvements in other
areas (Hoza, 2007; MTA Cooperative Group, 1999,
2004). Furthermore, psychoactive medication for
ADHD was not associated with having more friends
or being better accepted or less rejected (Bagwell,
Molina, Pelham, & Hoza, 2001; MTA Cooperative
Group, 1999, 2004; Mrug, Hoza, & Gerdes, 2001).
Professionals working with children with ADHD
commonly use play to explore behavioral and social dif-
culties. Furthermore, play provides a natural context
to address the interactional problems that children with
ADHD may experience. Given the importance of play
to social development, surprisingly little published re-
search exists on the impact of ADHD on play. The limit-
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123
ed research suggests that children with ADHD are less
playful (Leipold & Bundy, 2000), perform more poorly
on aspects of play that are inuenced by hyperactiv-
ity, impulsivity, and inattention (American Psychiatric
Association, 2000; Barkley, 2003), and have difculties
with the social dimensions of play (Hechtman et al.,
2005; MTA Cooperative Group, 1999, 2004).
The reason for the limited research on play could
be explained in part by the difculties in dening play,
which remains an elusive concept (Rubin, Fein, & Van-
denberg, 1983). Although there is some disagreement
about the exact characteristics that comprise play, play
is commonly dened by the characteristics that sepa-
rate it from non-play. Neumann (1971) proposed a
simple list: intrinsic motivation, internal control, and
suspension of reality. After the work of Bateson (1971,
1972), Bundy (e.g., Bundy, 2004; Skard & Bundy, 2008)
proposed the addition of a fourth characteristic: fram-
ing (reading and interpreting social cues). When play is
dened by these four traits, current literature provides
some indication of how the characteristics inherent to
ADHD and the elements of playfulness interact.
For the purposes of this study, play was dened
as a transaction between the individual and the en-
vironment that is intrinsically motivated, internally
controlled, and free of many of the constraints of objec-
tive reality and skills related to framing (giving and re-
sponding to cues) (Bateson, 1971, 1972; Skard & Bundy,
2008). Play manifests in children as playfulness (i.e., the
disposition to play) (Bundy, 2004; Neumann, 1971).
Using the Test of Playfulness (ToP) to operation-
alize the denition of play, we set out to explore the
similarities and differences in the play of children
with ADHD compared with typically developing
children. We tested the following hypotheses:
Hypothesis 1: The mean overall ToP score of chil-
dren with ADHD will be signicantly lower than
that of typically developing peers.
Hypothesis 2: The mean scores of children with
ADHD will be signicantly lower than those of
typically developing peers on ToP items that re-
ect the primary symptoms of ADHD (inatten-
tion, hyperactivity, and impulsivity).
Hypothesis 3: The mean scores of children with
ADHD will be signicantly lower than those of
their typically developing peers on items that re-
ect the social dimensions of play.
Method
Participants
This study compared 238 children between the ages
of 5 and 11 years who were divided into two groups.
Group 1 consisted of children diagnosed as having
ADHD who were paired with typically developing
playmates (one child with ADHD and one typically
developing child in each observation) and group 2
consisted of typically developing children who were
paired with a playmate who was also typically devel-
oping (two typically developing children in each ob-
servation). All playmate pairs were familiar with one
another. Children in group 2 and the playmates of chil-
dren with ADHD in group 1 were known not to have
ADHD as dened by the Diagnostic and Statistical Man-
ual of Mental Disorders, 4th edition (DSM-IV) criteria for
ADHD. Overall, children who were not procient in
English were excluded because use of English is neces-
sary for interpreting the ToP by an English speaking
rater. This investigation is part of a larger study; only
the children with ADHD in group 1 (not their play-
mates) and all children in group 2 will be discussed.
Children With ADHD. This group included 112
children with ADHD recruited from district health
boards and pediatricians practices in Auckland,
New Zealand. Diagnostic procedures were designed
to ensure high levels of diagnostic accuracy and to
minimize the inclusion of borderline cases (i.e., cases
just failing to reach criteria on the DSM-IV) and cas-
es diagnosed as something other than ADHD were
deemed the primary diagnosis.
To be included in the study, children had a formal
diagnosis of ADHD made by a psychiatrist or pedia-
trician according to DSM-IV criteria. Furthermore,
they were included if they had conditions known to
be comorbid to ADHD, such as learning disorders,
oppositional deant disorder, conduct disorder,
anxiety disorder, and mood disorderprovided that
ADHD was the primary diagnosis. They were ex-
cluded if they had other major neurodevelopmental
or psychiatric disorders, such as Autism spectrum
disorders, intellectual disabilities, movement or tic
disorders, and organic brain syndromes.
Additionally, we included children with ADHD
who were receiving the short-acting forms of meth-
ylphenidate given that their duration of action is 3 to
5 hours (American Academy of Child and Adolescent
Psychiatry, 2007; Physicians Desk Reference, 2007).
We excluded those taking the long-acting forms or
atomoxetine and children who took medication for
comorbid conditions. Parents or guardians were re-
quested not to administer medication prescribed for
ADHD on the day of the assessment because we were
interested to observe how ADHD affects play without
the effects of medication. Each of these children in-
vited a playmate of a similar age to the play session.
Typically Developing Children (Control Group).
This group included 126 children. They were recruit-
ed from professional networks such as local schools
Copyright American Occupational Therapy Foundation
124
and from families of health services employees. For
the purpose of this article, a typically developing
playmate was dened as a child who did not have
ADHD (i.e., scored below the clinical cut-off for
any of the Conners Parent Rating ScalesRevised
[CPRS-R] subscales and DSM-IV scales) and for
whom no concerns had been raised about develop-
ment by a teacher or health professional.
The demographic information from the partici-
pants and their primary caregivers is summarized
in Table 1. To assist with interpretation of the ToP
results, the mean CPRS-R subscale scores are sum-
marized in Table 2.
The children with ADHD and the typically devel-
oping children playing together were matched by
age groups (56, 78, and 911 years), sex, and eth-
nicity. Data on socioeconomic status were gathered,
but it was not possible to match the groups a priori
for socioeconomic status.
Instruments
The ToP (Bundy, 2004) was used to measure the
childrens play. It is a 29-item observer rated instru-
ment that can be administered to any individual be-
tween the ages of 6 months and 18 years. Each item
is rated on a 4-point (03) scale. Scores reect either
extent (proportion of time), intensity (degree of pres-
ence), or skillfulness (ease of performance). The ToP
measures the concept of playfulness as a reection of
the combined presence of four elements contributing
to a single (unidimensional) construct of playfulness:
perception of control, freedom from constraints of
reality, source of motivation, and ability to give and
read social cues. Although the ToP was designed to
represent a theoretical conceptualization of playful-
ness comprising multiple elements, playfulness is a
single construct; thus, it is not feasible to analyze data
by the four elements (Bundy, 2004). One overall scaled
score is calculated with a mean of 50 and a standard
deviation of 10. Table 3 provides item descriptions.
The ToP is administered in an environment that
is supportive of play and has evidence for excellent
inter-rater reliability (data from 96% of raters t the
expectations of the Rasch model), construct valid-
ity (e.g., data from 93% items and 98% of people
t Rasch expectations) (Bundy, Nelson, Metzger, &
Bingaman, 2001), and moderate testretest reliability
(e.g., intraclass correlation 0.67 at p < .01; Brentnall,
Table 1
Participant Demographics
Variables
Group 1
Children With ADHD
Group 2
Typically Developing Children
Mean age (y) 8.9 8.6
Gender
a
Male 80.3% 78.7%
Female 19.7% 21.3%
Ethnicity
b
European 67.8% 65.2%
Maori 16.1% 19.7%
Other ethnicities 16.1% 15.1%
Primary caregivers highest level of education
Did not complete high school 13.4% 19.1%
Completed high school 40.2% 46.8%
Completed tertiary qualifications 46.4% 34.1%
Primary caregivers occupation
Jobs that do not require tertiary qualifications 63.4% 75.4%
Jobs that do require tertiary qualification 36.6% 24.6%
ADHD = attention deficit hyperactivity disorder.
a
This is a close approximation to the 1:5 ratio of boys to girls diagnosed as having ADHD reported in the literature (American Psychiatric Association, 2000;
Barkley, 2006b; Tannock, 1998).
b
This is a close approximation of the current ethnic distribution of the New Zealand population estimate (Statistics New Zealand, 2007) with Europeans
comprising 76.8%, Maori comprising 14.9%, and the remainder of ethnic groups comprising 17.8% of the population, thus representative of the New Zealand
population.
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125
Bundy, & Kay, 2008). All play sessions were video
recorded for detailed analysis after observation us-
ing the ToP.
The CPRS-R was administered for all children
in the sample. The CPRS-R is a paper-and-pencil
screening questionnaire completed by the parents or
guardians to assist in determining whether children
between the ages of 3 and 17 years have signs and
symptoms consistent with the diagnosis of ADHD.
The CPRS-R has evidence of excellent reliability
(international consistency reliability 0.750.94) and
construct validity (to discriminate ADHD from the
non-clinical group: sensitivity = 92%, specicity =
91%, positive predictive power = 94%, negative pre-
dictive power = 92%) (Conners, 2004; Conners, Sitar-
enios, Parker, & Epstein, 1998). The CPRS-R is one of
the assessment tools most commonly used through-
out the world in the diagnosis of ADHD (Hale, How,
Dewitt, & Coury, 2001); it produces subscale scores,
expressed as t scores, ranging between 0 and 100.
For the children with ADHD, clinical cut-off scores
from the CPRS-R were used to conrm the diagno-
sis of ADHD and to screen for comorbid conditions
(e.g., oppositional deant disorder and anxiety) in
addition to the diagnosis made by the pediatrician
or psychiatrist. The CPRS-R was also used for the
playmates and children in the control group to en-
sure the absence of ADHD. The mean scores of the
CPRS-R subscales (cognitive problems, oppositional
behavior, anxious or shy, perfectionism, social prob-
lems, psychosomatic, emotional lability, and behav-
ioral problems) were used to assist in the interpreta-
tion of ToP ndings.
Procedure
Ethical approval was obtained from the Univer-
sity of Sydney Human Ethics Research Commit-
tee and the Northern Y Regional Ethics Commit-
tee, New Zealand. For convenience of the families
and to ensure familiarity of the play environments,
data for the two groups were gathered in different
but equivalent settings. The environment where
data were gathered for children with ADHD was a
playroom set up specically for the assessment in a
clinical setting where the children with ADHD came
regularly for assessment or intervention. The play
environment for children in the control group was
a designated play area at the respective schools that
children in the control group attended.
According to Bundy (2004), the environment
should be one in which the child feels physically and
emotionally safe to increase chances for spontaneous
and intrinsically motivated play behavior to occur.
The categories of the Test of Environmental Support-
iveness (TOES) were used as guidelines for establish-
ing play spaces with the maximum chance of promot-
ing play. The TOES operationalizes the ways in which
four aspects of the environment inuence players
motivation to play: playmates, objects, play space,
and the sensory environment (Skard & Bundy, 2008).
The toy selection catered to gender differences,
the age range of the children, and their likely mo-
tivations for engaging in free play. A diversity of
play materials was present in each room to support
a range of play. The same toys were present during
all play sessions and the children were allowed to
choose play materials and activities.
Table 2
Conners Parent Rating ScaleRevised Subscale Scores
Subscales Subscale Description
ADHD (n = 112)
Mean Scores
Control (n = 126)
Mean Scores
Oppositional behavior Break rules, problems with authority, or easily
annoyed
70.4
a
50.6
Cognitive problems Learn slowly, organizational problems, difficulty
completing tasks, or concentration problems
72.5
a
49.5
Anxious or shy Have worries or fears, emotional, sensitive to criti-
cism, shy, or withdrawn
58.9 50.8
Perfectionism Set high goals, fastidious, or obsessive 56.1 49.3
Social problems Have few friends, low self-esteem and self-confi-
dence, or feel emotionally distant from peers
76.0
a
48.9
Psychosomatic Report an unusual amount of aches and pains 64.4 50.6
Emotional lability Emotional, cry a lot, or get angry easily 62.8 48.5
Behavioral problems Broad ranged behavioral problems 73.0
a
49.7
ADHD = attention deficit hyperactivity disorder.
a
Conners Parent Rating ScalesRevised subscale mean scores above the clinical cut-off (i.e., subscale scores > 70).
Copyright American Occupational Therapy Foundation
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Table 3
Pairwise Bias Interaction of Children With ADHD and Typically Developing Children in the Control Group With Test of
Playfulness Item Descriptions and Corresponding t Values and Probabilities
Item
ADHD
Mean
a
Control
Mean
a

ADHD
SD
a
Control
SD
a
ADHD t
b

(df = 173) p
Perception of control
1 Skill of initiating new activities 1.80 2.05 0.94 0.85 0.00 .99
2 Skill of negotiating needs 1.93 1.54 0.97 0.69 2.06 .03
c
3 Extent of deciding what to do 2.98 3.00 0.13 0.01 -0.08 .94
4 Skill of sharing ideas or objects 2.40 2.79 0.74 0.43 -3.00 < .01
c
5 Skill of supporting the play of others 1.64 2.15 0.99 0.75 -2.81 .01
c
6 Intensity of interacting with objects 2.63 2.68 0.54 0.48 1.49 .14
7 Skill of interacting with objects 1.97 2.01 0.31 0.20 2.25 .06
8 Skill of modifying task requirements 1.97 2.18 0.76 0.67 0.40 .69
9 Skill of transitioning between activities 1.96 2.39 0.68 0.61 -2.26 .03
c
10 Extent of playing with others 2.29 2.43 0.69 0.64 0.81 .42
11 Intensity of playing with others 2.00 2.46 0.79 0.63 -2.63 .01
c
12 Skill of playing with others 1.88 2.30 0.76 0.64 -2.00 .05
c
Freedom from constraints of reality
13 Extent of pretending 0.96 1.21 0.74 0.73 -0.14 .89
14 Skill of pretending 1.20 1.73 0.43 0.67 -2.94 .05
c
15 Extent of using people or objects
unconventionally
0.96 1.10 0.68 0.69 1.00 .32
16 Skill of using people or objects
unconventionally
0.97 1.28 0.74 0.90 -0.73 .47
17 Extent of using mischief/teasing 0.74 0.58 0.71 0.71 3.91 < .01
c
18 Skill of using mischief/teasing 1.86 2.00 0.46 0.32 1.18 .24
19 Extent of using clowning/joking 0.58 0.70 0.68 0.68 0.79 .44
20 Skill of using clowning/joking 2.00 2.03 0.20 0.58 0.66 .51
Source of motivation
21 Extent of being engaged 2.66 2.77 0.50 0.42 0.57 .57
22 Intensity of being engaged 2.32 2.44 0.60 0.57 1.02 .31
23 Extent of being involved in the process 2.88 2.69 0.35 0.50 5.36 < .01
c
24 Intensity of persistence 1.20 1.35 0.66 0.62 0.99 .32
25 Intensity of showing positive affect 1.45 1.67 0.67 0.64 0.35 .73
Framing (play cues)
26 Skill of being engaged 1.56 1.79 0.65 0.70 0.23 .82
27 Extent of giving cues 2.38 2.54 0.66 0.62 0.53 .60
28 Skill of giving cues 2.43 2.65 0.73 0.57 -0.44 .66
29 Skill of responding to cues 2.22 2.75 0.72 0.50 -3.94 < .01
c
ADHD = attention deficit hyperactivity disorder.
a
Mean and standard deviation (SD) scores were derived from the raw scores (Rasch does not provide item measure mean and standard deviation scores) and
needs to be interpreted with caution.
b
Our hypotheses state that there is no more differential item functioning in each of these items, considered one at a time, than could occur by accident; there-
fore, each t test stands by itself and no Bonferroni adjustment (or another similar procedure) is indicated (Linacre, 2008).
c
Denotes significant (t > 1.96; p < .5).
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127
Approximately 60% of the playmates of children
with ADHD were siblings because that proportion
of the children with ADHD identied that they did
not have another usual playmate. The assessor tried
to make participants feel at ease prior to the inter-
active free play session by introducing them to the
play situation. Participants were instructed that they
could play with any of the toys in the playroom for
20 minutes and that they should ignore the assessor
who was present in the play room. The assessor was
as unobtrusive as possible and had been instructed
to not intervene unless a child was in danger. When
children attempted to interact with the assessor, the
assessors response was neutral.
A single experienced rater assessed all of the chil-
dren from the videotapes. Prior to scoring, the rater
was calibrated on the ToP, which means the consis-
tency of her ratings was compared with that of hun-
dreds of other raters in a larger ToP sample (n > 3,000
observations); her calibration results demonstrated
that she is a reliable rater because her goodness of t
statistics were within an acceptable range (see Facets
generated goodness of t statistics in the Data Analy-
sis section). To ensure that her scores did not drift, the
rater rescored approximately 20% of the videotapes,
which were randomly selected. Data from both test
administrations were analyzed with Facets software
(see Data Analysis section); scores for each child were
compared for time 1 versus time 2 and found to be
equivalent because the overall scores differed by
more than the standard error of measurement. The
rater did not participate in any other aspect of the
study and was blinded to the purpose of the study to
minimize bias.
Data Analysis
To attain interval level scores for each participant,
raw ToP scores were subjected to Rasch analysis
using the Facets program (version 3.62.0; Linacre,
2007). The resulting measure scores were then en-
tered into t tests used to compare differences be-
tween the means of the groups using SPSS version 15
(SPSS Inc., Chicago, IL). Differences between means
of the groups are regarded as signicant at t > 1.96
and t < -1.96 (Coakes & Steed, 2007). Prior to further
calculations, however, we examined the goodness of
t statistics for people and items to ensure that they
were within an acceptable range set a priori (MnSq <
1.4; standardized value < 2; Bond & Fox, 2007); this
ensured that the measure scores were true interval
level measures.
The Facets program also checks for bias speci-
ers between the model and specications. Bias in-
teraction analysis, also called differential item func-
tioning, was used to examine the ToP items to see
whether the items have signicantly different mean-
ings for the two groups, indicated by any signicant
differences in how children performed on each ToP
item for each diagnostic group (ADHD vs. control).
Rasch bias interaction statistical procedures identify
items that do not maintain stable difculty param-
eters across population subgroups (Wendt & Surges-
Tatum, 2005). This enables the measurement of bias
interaction for each ToP item that contributes toward
the statistical model (Linacre, 2007). The specied
bias interaction is estimated for all data (not just the
data matching that particular model).
Because the children with ADHD in group 1 were
compared with pairs of typically developing children
in the control group, the children in the control group
observations were weighted at 0.5 to address any po-
tential bias in the analysis, enabling pairwise analysis
(Linacre, 2007). Pairwise bias interaction is used to
correct for estimation bias when the data correspond
to pairwise observations (such as dyads playing to-
gether). The pairwise bias interaction for each item
and diagnostic group is expressed as a t value.
Bias interaction analyses generated by the Facets
program also can be used to ensure equivalence of
the groups with respect to potentially confounding
variables. We tested the effects of nine such vari-
ables: (1) sex, (2) age (in three groups: 56, 78, and
911 years), (3) ethnicity, (4) socioeconomic status,
(5) younger versus older sibling playmates, (6) age
difference between playmate pairs, (7) sibling versus
peer playmates, (8) clinically signicant opposition-
al deant disorder symptoms versus non-clinically
signicant oppositional deant disorder symptoms,
and (9) clinically signicant anxiety symptoms ver-
sus non-clinically signicant anxiety symptoms. All
signicance p levels were .05 or less.
Results
Prior to any other analyses, we examined the good-
ness of t for data from the items and children. Fit sta-
tistics from all but one item (Feels Safe) were within
the accepted range; we removed that item because it
seemed to reect an artifact of the setting. Data from
four children were outside the range, so we ran all
analyses both with and without those children and,
nding no differences, retained their data.
We then tested for the effects of the confound-
ing variables listed above. None of the results was
signicant (t < 1.96; p < .05). We interpreted this to
mean that none of the confounding variables that we
tested (e.g., comorbid oppositional deant disorder
or anxiety) accounted for the observed differences.
Copyright American Occupational Therapy Foundation
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Hypothesis 1
The hypothesis that the mean overall ToP score
for children with ADHD will be signicantly lower
than that of typically developing peers was support-
ed. A t test for independent samples revealed that
the children with ADHD were less playful than the
typically developing children (ADHD mean mea-
sure score = 1.09; ADHD standard deviation = 1.28;
control mean measure score = 1.99; control standard
deviation = 0.82; t = -13.9; p < .01; df = 125). The re-
sults of the pairwise bias interactions comparing the
performance of the groups on each item are shown
in Table 3. In the remainder of the discussion, the
ToP item numbers, as shown in Table 3, are used in
brackets for reference.
Hypothesis 2
The hypothesis that the mean scores of children
with ADHD will be signicantly lower than those of
typically developing peers on ToP items that reect
the primary symptoms of ADHD (inattention, hy-
peractivity, and impulsivity) was not supported. By
denition, six ToP items relate directly to the prima-
ry symptoms of ADHD. These items include the skill
to initiate new activities (1); intensity of interaction
with objects (6); skill to modify activities (8); extent
of being engaged (21); intensity of engagement in an
activity (22); and ability to persist with an activity
(24). Table 4 provides a summary of the descriptions
of the ToP items and their relationship to the charac-
teristics of the primary symptoms of ADHD. Chil-
dren with ADHD did not perform signicantly more
poorly on any of these six items.
Hypothesis 3
The hypothesis that the mean scores of children
with ADHD will be signicantly lower than those of
their typically developing peers on items that reect
the social dimensions of play was partially support-
ed. Eight ToP items represent the social dimension
of play (i.e., items that require social interaction to
be scored): skill to initiate (1), negotiate (2), share (4)
and support the play of others (5); extent of social
play (10); intensity of social play (11); and skill of so-
cial play (12) and responding to cues (29). Children
with ADHD performed signicantly more poorly on
ve of the eight social items: shares (4); support (5);
intensity (11) and skill of social play (12); and skill
in responding to cues (29) (Table 3). However, of the
remaining three social items, children with ADHD
performed signicantly better than typically devel-
oping children on skill to negotiate (2). There was
not a signicant difference for the skill to initiate (1)
or extent of social play (10).
Discussion
We set out to examine the similarities and differenc-
es in the play of children with ADHD compared with
that of their typically developing peers. In particular,
we attempted to determine whether children with
ADHD are less playful compared with typically de-
veloping peers, unravel the impact of primary symp-
toms of ADHD (i.e., inattention, hyperactivity, and
impulsivity) on the play of children with ADHD, and
examine the social concomitants of ADHD as mani-
fested in play. Although, as expected, we found overall
differences between the groups, the details of what we
found are notable for both what we expected but did
not nd and what we discovered unexpectedly.
Surprisingly, none of the ToP items that relate di-
rectly to the primary symptoms of ADHD differed
signicantly between children with ADHD and typi-
cally developing children, suggesting that the primary
symptoms of ADHD did not account for the overall
differences and did not appear to impair the play of
children with ADHD in a directly observable manner,
at least as measured by the ToP. This nding may be
explained by the play situation, which was designed to
be particularly appealing to increase the chances that
play occurred. Apparently, the high level of appeal off-
set the primary symptoms of ADHD (Diamond, 2005).
Children with ADHD had difculty in the pre-
ponderance of ToP social items (5 of 8), thus under-
scoring the social difculties they experience. These
differences could not be attributed to the fact that
more than half of the children with ADHD identied
that they did not have friends and thus chose to play
with a sibling. Although there was no observable
difference in the proportion of time children with
ADHD and typically developing children interacted
with playmates, the intensity of that interaction was
signicantly less for children with ADHD and they
were less skilled at social play compared with typi-
cally developing children in the control group.
Similarly, children with ADHD gave clear social
cues (27 and 28), but were signicantly less able to re-
spond to others cues than typically developing peers
(29). Taken together, these ndings suggest that chil-
dren with ADHD seek out social interaction as much
as typically developing children (11) do, but they
struggle as the transaction becomes more intense (12),
perhaps because they nd responding to playmates
cues (29) more difcult than typically developing
peers do (responding to cues is, for most children, an
easy itemin the bottom 20% overall when ToP items
are ranked hardest [top] to easiest [bottom]).
This nding is supported by the mean score chil-
dren with ADHD have on the CPRS-R social prob-
OTJR: Occupation, Participation and Health Vol. 30, No. 3, 2010
129
lems and general behavioral problems subscales
(76.0 and 73.0, respectively), which are above the
clinical cut-off. (Note: Higher scores indicate greater
difculty.) However, compared with children in the
control group, children with ADHD performed bet-
ter on skill to negotiate (2) and there were no signi-
cant differences for initiates (1) and extent of social
play (10), suggesting that poor social skills may not
fully explain the difculties they experience in play.
The ToP items on which children with ADHD
were signicantly less playful than the typically de-
veloping children (Table 5) are primarily reective
of poor social skills. One might stop at that simple
explanationexcept that the children with ADHD
also were better at negotiating (2) and performed
similar to children in the control group on initiating
play (1), two reasonably high-level social skills. Tak-
en collectively, the items on which the children with
ADHD were both less skilled and the ones in which
they were as skilled or more skilled is reminiscent of
another constructinterpersonal empathy.
The term empathy implies both affective and cog-
nitive dimensions (Feshbach, 1997; Strayer, 1987). Em-
pathy, as described by Feshbach and applied to the
ToP items (see Table 5 where ToP items were matched
with the corresponding components of the empathy
construct), comprises the ability to discriminate and
identify the emotional states of another (ToP item 29),
the capacity to take the perspective or role of the other
(ToP items 4, 9, and 14), and the evocation of a shared
affective response (ToP items 5, 11, and 12). The scoring
criteria for low ToP scores (as reected in Table 5) are
derived directly from the ToP manual (Bundy, 2004).
Proposed explanations are offered for the preponder-
ance of those low scores of children with ADHD.
Lack of empathy is characteristic of all young chil-
dren (Piaget, 1962). As children mature during their
early school years, empathetic thinking and respond-
ing evolves and children learn that others have ideas
and views different from their own (Frith & De Vi-
gnemon, 2005). By early school age (the age of the
children in this study), children are better able to take
on others viewpoints and are less occupied with their
own viewpoint; they become more decentered.
Table 4
Primary Symptoms of Attention Deficit Hyperactivity Disorder and Test of Playfulness Items
Meaning of Low Scores ADHD DSM-IV Criteria
a
Interpretation
Initiate new activities (1):
Players attempt to initiate play
destructively or do not try to initiate
activities that can be readily identi-
fied as play
Impulsivity: Often interrupts or intrudes
on others (e.g., butts into games)
Players may tend to initiate play
destructively due to impulsivity
Intensity of interaction with objects (6):
Players do not get involved with
objects
Inattention: Often has difficulty orga-
nizing tasks and activities and loses
things necessary for tasks or activities
(e.g., toys)
Players interaction with objects may be
superficial due to inattention
Modify activities (8):
Players simply repeat the activity or
the activity does not seem to evolve
Inattention: Often fails to give close
attention to details in activities
Players may have difficulty adapting
play due to inattention
Extent of engagement (21):
Players often do not engage in pur-
posefully selected activity, wander
aimlessly, or participate in a non-
focused activity
Inattention: Often has difficulty sustain-
ing attention in tasks or play activi-
ties
Players may often have difficulty focus-
ing on an activity due to inattention
and hyperactivity
Hyperactivity: Often has difficulty play-
ing quietly
Intensity of engagement (22):
Players have great difficulty concen-
trating on the activity
Inattention: Often has difficulty sustain-
ing attention in tasks or play activi-
ties
Players may interact superficially due to
inattention and hyperactivity
Hyperactivity: Often has difficulty play-
ing quietly
Persist with an activity (24):
Players have difficulties following
through on activities
Inattention: Often does not follow
through on tasks
Players may have difficulties persisting
due to inattention
ADHD = attention deficit hyperactivity disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th edition.
a
Excerpts from the DSM-IV criterion for ADHD (American Psychiatric Association, 2000).
Copyright American Occupational Therapy Foundation
130
Our results suggest that children with ADHD
have difculty in this regard, as evidenced by their
difculties responding to others play cues, sharing
resources and ideas, and supporting others play,
and their supercial or destructive interactions with
other players. Observed within the context of play,
their lower level of interpersonal empathy manifests
because the children are self-absorbed and focused
on having their own play needs met. They negotiate
to have their play needs met and give social cues,
but do not always respond to others cues. Although
they may use skills typically associated with highly
skillful play such as playful mischief, they often use
these strengths primarily to achieve their own goals.
Unsurprisingly, playmates of children with ADHD
often describe them as domineering and controlling
(Barkley, 2006a; Melnick & Hinshaw, 1996).
We conclude that children with ADHD seem to lag
developmentally in their capacity to decenter, a key to
empathy. As a continued reection of their diminished
empathy, children with ADHD seemed to lack insight
into the importance of reciprocity; thus the play frame
was often disrupted. Their impaired play illuminates
the essence of the social problems children with ADHD
experience in their developmental course.
Less empathetic responding in children with ADHD
has been proposed previously by Barkley (1997) in his
model of constructing a unifying theory for ADHD.
Barkley (1994) supposed that people with ADHD
would be less responsive to the needs, feelings, and
opinions of others (i.e., be less empathetic), stemming
from a reduced ability to interpret events from others
viewpoints that was the result of poor inhibitory con-
trol. Braaten and Rosen (2000) subsequently supported
this hypothesis. However, their study did not measure
empathy as an observable behavior, but rather inferred
this from how children with ADHD reported they felt
about other children. Furthermore, the small sample
size limited generalization of the ndings.
Lack of empathetic responding has also been re-
Table 5
Interpretation of Items With Low Test of Playfulness Scores
ToP Item
Scoring Criteria for
Low ToP Scores Proposed Explanation
Discriminate and identify the emotional states
of others
Item 29: skill in responding to play cues The player does not respond or
responds in a negative or hurtful
way to the playmates cues
Players are not sensitive or in tune
with others needs
Take the perspective or role of the other
Item 4: skill of sharing The player refuses to share or seems
unaware that he or she possesses
something another would like
Players are focused on having their
own needs met
Item 9: skill to transition between activities The player gets stuck on an activ-
ity that is not meeting the needs of
players or constantly goes from one
activity to another
Players have difficulty assessing the
play situation to remain engaged
in play
Item 14: skill in pretend play The player seems to have little ability
to convince onlookers that some-
thing about the play is no longer
based in reality
Players have difficulty imagining or
taking on anothers perspective
or point of view
Evocation of a shared affective response
Item 5: skill to support The player is concerned almost entire-
ly with meeting his or her own
needs rather than enabling others
to play
Players are not sensitive or in tune
with others needs
Item 11: intensity of social play The player does not get intensely
involved with playmates present
Interaction with others is superficial
Item 12: skill in social play The player interacts in a destructive
fashion or does not interact despite
the presence of others
Players struggle to move outside
their own frame and interact
with other players
ToP = Test of Playfulness.
OTJR: Occupation, Participation and Health Vol. 30, No. 3, 2010
131
ported in studies conducted on both oppositional de-
ant disorder and conduct disorder (American Psychi-
atric Association, 2000; Cohen & Strayer, 1996). Being
less empathetic may have signicant implications for
prosocial development, particularly because play is
the milieu within which children develop social skills
and form peer relationships. Both Barkley (1997) and
Hartup (1996) emphasized the importance of empa-
thy for prosocial behavior, and it is known that many
children with ADHD continue to have serious social
difculties throughout adolescence and adulthood
(Barkley, 2006a; Schachar, 1991; Wood, 1995).
We did not set out to examine empathetic response
in children with ADHD. Although social concomitants
of ADHD are well documented, the nding that social
difculties seem to reect lower levels of empathy was
unexpected. Furthermore, we consider that these nd-
ings may, in fact, underestimate the degree of the prob-
lem. Children with severely disruptive behavior and
more complex presentations of ADHD were likely to
have been excluded from the study, both as a function
of the strict adherence to exclusion criteria and the fact
that participation in the study was voluntary. Thus, it
is less likely that children with complex presentation
and needs participated in the study. If more children
with ADHD with complex presentations had been in-
cluded, the phenomena of lack of empathetic response
might have been even more pronounced. Further re-
search clearly is necessary.
Limitations
It was not feasible to draw a random sample.
Hence, the ability to generalize the results of this
study to children with ADHD in other populations
is somewhat limited. However, the strength of the
results indicates the need for further research.
Conclusions and Implications
Our interpretation of the constellation of scores led
us to suggest that the play of children with ADHD is
characterized by lower levels of empathetic respond-
ing. Clearly, further research is needed to replicate
the ndings. Lower social skills and less empathy
can have adverse implications for the development
of morality and can potentially lead to anti-social be-
havior. The results suggest that consideration should
be given to the process of decentering when planning
interventions for children with ADHD.
Therefore, features such as the ability to discrimi-
nate and identify the emotional states of playmates, the
capacity to take on playmates perspectives or roles,
and the evocation of shared affective needs have to be
included in the design of early intervention play-based
therapy for children with ADHD. Interventions aimed
at decentering that have proven effective include using
nascent collective symbolism where playmates practice
imitation with same symbolic meaning to actions dur-
ing pretend play (e.g., both players know that handing
each other pieces of paper represents payment) (Hoff-
man, 2001) and collective pretend play, which involves
shared cooperative activities and joint creation of char-
acters (Stambak & Sinclair, 1993).
Acknowledgments
This study was completed by the rst author as part of
the requirements for the completion of a PhD under su-
pervision of the other authors. The authors wish to ac-
knowledge the Australian Government for EIPRS and IPA
scholarships, and express their gratitude to the families
who participated in the research and particularly the staff
from Whirinaki, Kari and Marinoto North Child and Ado-
lescent Mental Health Services, New Zealand.
References
American Academy of Child and Adolescent Psychiatry. (2007).
Practice parameter for the assessment and treatment of chil-
dren and adolescents with attention deficit hyperactivity
disorder. Journal of American Academy of Child and Adolescent
Psychiatry, 46, 894-921.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th, text revised ed.). Washington,
DC: Author.
Bagwell, C. L., Molina, B. S. G., Pelham, W. E., & Hoza, B. (2001).
Attention deficit hyperactivity disorder and problems in peer
relations: Predictions from childhood to adolescence. Journal
of American Academy of Child and Adolescent Psychiatry, 40,
1285-1292.
Barkley, R. A. (1994). Impaired delayed responding: A unified
theory of attention deficit hyperactivity disorder. In D. K.
Routh (Ed.), Disruptive behavior disorders in childhood (pp. 11-
57). New York: Plenum.
Barkley, R. A. (1997). Attention deficit hyperactivity disorder, self
regulation, and time: Toward a more comprehensive theory.
Developmental and Behavioral Pediatrics, 18, 271-279.
Barkley, R. A. (2003). Issues in the diagnosis of attention deficit
hyperactivity disorder in children. Brain and Development, 25,
77-83.
Barkley, R. A. (2006a). A theory of ADHD. In R. A. Barkley (Ed.),
Attention deficit hyperactivity disorder: A handbook for diagnosis
and treatment (3rd ed., pp. 297-336). New York: Guilford.
Barkley, R. A. (2006b). Primary symptoms, diagnostic criteria,
prevalence, and gender differences. In R. A. Barkley (Ed.),
Attention deficit hyperactivity disorder: A handbook for diagnosis
and treatment (3rd ed., pp. 76-121). New York: Guilford.
Bateson, G. (1971). The message, this is play. In R. E. Herron &
B. Sutton-Smith (Eds.), Childs play (pp. 261-269). New York:
Wiley & Sons.
Bateson, G. (1972). Toward a theory of play and phantasy. In G.
Bateson (Ed.), Steps to an ecology of the mind (pp. 14-20). New
York: Bantam.
Bond, T. C., & Fox, C. M. (2007). Applying the Rasch model:
Fundamental measurement in the human sciences (2nd ed.).
Copyright American Occupational Therapy Foundation
132
Mahwah, NJ: Lawrence Erlbaum.
Braaten, E. B., & Rosen, L. A. (2000). Self-regulation of affect
in attention deficit hyperactive disorder (ADHD) and non-
ADHD boys: Differences in empathic responding. Journal of
Consulting and Clinical Psychology, 68, 313-321.
Brentnall, J., Bundy, A., & Kay, F. C. S. (2008). The effect of the
length of observation of Test of Playfulness Scores. OTJR:
Occupation, Participation and Health, 28, 133-140.
Bundy, A. (2004). Test of Playfulness (ToP). Version 4.0. Sydney,
Australia: University of Sydney.
Bundy, A. C., Nelson, L., Metzger, M., & Bingaman, K. (2001).
Validity and reliability of a test of playfulness. The Occupational
Therapy Journal of Research, 21, 276-292.
Coakes, S. J., & Steed, L. (2007). SPSS (Version 14.0 for windows).
Analysis without anguish. Singapore: Fabulous Printers.
Cohen, D., & Strayer, J. (1996). Empathy in conduct-disordered
and comparison youth. Developmental Psychology, 32, 988-998.
Conners, C. K. (2004). Validation of ADHD Rating Scales: Dr.
Conners replies. Journal of the American Academy of Child and
Adolescent Psychiatry, 43, 1190-1191.
Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N.
(1998). The revised Conners Parent Rating Scale (CPRS-R):
Factor structure, reliability, and criterion validity. Journal of
Abnormal Child Psychology, 26, 257-268.
Crick, N., & Dodge, K. (1994). A review and reformulation of
social information-processing mechanisms in childrens social
adjustment. Psychological Bulletin, 115, 74-101.
Diamond, A. (2005). Attention deficit disorder (attention deficit
hyperactivity disorder without hyperactivity): A neurobiolog-
ically and behaviorally distinct disorder from attention deficit
hyperactivity disorder (with hyperactivity). Development and
Psychopathology, 17, 807-825.
Erdley, C., & Asher, S. (1999). A social goals perspective on chil-
drens social competence. Journal of Emotional and Behavioral
Disorders, 7, 156-168.
Feshbach, N. D. (1997). Empathy: The formative years:
Implications for clinical practice. In A. C. Bohart & L. S.
Greenberg (Eds.), Empathy reconsidered: New directions in
psychotherapy (1st ed., pp. 33-59). Washington, DC: American
Psychological Association.
Frith, U., & De Vignemon, F. (2005). Egocentrism, allocentrism,
and Asperger syndrome. Consciousness and Cognition, 14,
719-738.
Hale, J. B., How, S. K., Dewitt, M. B., & Coury, D. L. (2001).
Discriminant validity of the Conners Scales for ADHD sub-
types. Current Psychology, 20, 231-249.
Hartup, W. W. (1996). The company we keep: Friendships and
their developmental significance. Child Development, 67, 1-13.
Hechtman, L., Etcovitch, J., Platt, R., Arnold, L. E., Abikoff, H.
B., Newcorn, J. H., et al. (2005). Does multimodal treatment
of ADHD decrease other diagnoses? Clinical Neuroscience
Research, 5, 273-282.
Hoffman, M. L. (2001). Empathy and moral development: Implications for
caring and justice. Cambridge, England: Cambridge University.
Hoza, B. (2007). Peer functioning in children with ADHD. Journal
of Pediatric Psychology, 32, 655-663.
Hoza, B., Mrug, S., Pelham, W. E., Greiner, A. R., & Gnagy, E. M.
(2003). A friendship intervention for children with attention
deficit hyperactivity disorder: Preliminary findings. Journal of
Attention Disorders, 6(3), 87-98.
Leipold, E. E., & Bundy, A. (2000). Playfulness in children
with attention deficit hyperactivity disorder. The Occupational
Therapy Journal of Research, 20, 61-82.
Linacre, J. M. (2007). Winsteps Rasch Measurement: Computer soft-
ware and manual (Version 3.62.0). Available at: http://www.
winsteps.com.
Melnick, S., & Hinshaw, S. (1996). What they want and what they
get: The social goals of boys with ADHD and comparison
boys. Journal of Abnormal Child Psychology, 24, 169-185.
Mrug, S., Hoza, B., & Gerdes, A. C. (2001). Children with atten-
tion deficit hyperactivity disorder: Peer relationships and
peer-oriented interventions. In D. W. Nangle & C. A. Erdley
(Eds.), The role of friendship in psychological adjustment (pp. 51-
77). San Francisco: Jossey-Bass.
MTA Cooperative Group. (1999). A 14-month randomized clinical
trial of treatment strategies for attention deficit hyperactivity
disorder. Archives of General Psychiatry, 56, 1073-1086.
MTA Cooperative Group. (2004). Attention deficit hyperactivity
disorder follow-up: 24-month outcomes of treatment strate-
gies for National Institute of Mental Health multimodal treat-
ment study of ADHD. Pediatrics, 113, 754-761.
Neumann, E. A. (1971). The elements of play. New York: MSS
Information.
Ollendick, T. H., Weist, M. D., Borden, M. C., & Greene, R. W.
(1992). Sociometric status and academic, behavioral, and psy-
chological adjustment: A five-year longitudinal study. Journal
of Consulting and Clinical Psychology, 60, 80-87.
Physicians Desk Reference. (2007). 61st ed. Montvale, NJ:
Thomson Healthcare.
Piaget, J. (1962). Play dreams and imitation in childhood (C. Gattegno
& C. Hodgson, Trans.). New York: W. W. Norton.
Rubin, K., Fein, G. G., & Vandenberg, B. (1983). Play. In E. M.
Hetherington (Ed.), Handbook of child psychology: Social develop-
ment (4th ed., Vol. 3, pp. 693-774). New York: Wiley.
Schachar, R. (1991). Childhood hyperactivity. Journal of Child
Psychology and Psychiatry, 32, 155-191.
Skard, G., & Bundy, A. (2008). Test of Playfulness. In L. D. Parham
& L. S. Fazio (Eds.), Play in occupational therapy for children (2nd
ed., pp. 71-93). St. Louis: Mosby.
Stambak, M., & Sinclair, H. (1993). Pretend play among 3-year olds.
Hillsdale, NJ: Lawrence Erlbaum.
Statistics New Zealand. (2007). National population estimates
June 2007 quarter. Retrieved November 2, 2007, from http://
www.stats.govt.nz/products-and-services/hot-off-the-
press/national-population-estimates/national-population-
estimates-jun07-qtr-hotp.htm.
Strayer, J. (1987). Affective and cognitive perspective on empathy.
In N. Eisenberg & J. Strayer (Eds.), Empathy and its development
(pp. 218-244). Cambridge, England: Cambridge University.
Tannock, R. (1998). Attention deficit hyperactivity disorder:
Advances in cognitive, neurobiological, and genetic research.
Journal of Child Psychology and Psychiatry, 39, 65-99.
Wendt, A., & Surges-Tatum, D. (2005). Credentialing health care
professionals. In N. Bezruczko (Ed.), Rasch Measurement in
Health Sciences: Measurement Axioms (pp. 161-175). Maple
Grove, MN: JAM.
Wood, K. (1995). Attention deficit hyperactivity disorder: A guide for
professionals. Melbourne: La Trobe University.
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