Evaluation of A Pilot Parent-Delivered Play-Based Intervention For Children With Attention Deficit Hyperactivity Disorder

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Evaluation of a Pilot Parent-Delivered Play-Based

Intervention for Children With Attention Deficit


Hyperactivity Disorder

Sarah Wilkes-Gillan, Anita Bundy, Reinie Cordier, Michelle Lincoln

MeSH TERMS OBJECTIVE. This study evaluated a parent-delivered intervention aiming to address the social difficulties
 attention deficit disorder with of children with attention deficit hyperactivity disorder (ADHD). The intervention was evaluated from three
perspectives: effectiveness, feasibility, and appropriateness.
hyperactivity
METHOD. This one-group pretest–posttest study included 5 children with ADHD and their parents, who
 interpersonal relations
had previously participated in a therapist-delivered play-based intervention. The 7-wk parent-delivered
 parents
intervention involved home modules (including a DVD, manual, and play dates with a typically developing
 play therapy playmate) and three therapist-led clinic-based play sessions. The Test of Playfulness was used as a pre-
 treatment outcome and postintervention and follow-up measure. Parents were interviewed 1 mo following the intervention, and
data were analyzed for recurring themes.
RESULTS. Children’s social play outcomes improved significantly from pretest to 1-mo follow-up (Z 5
2.02, p 5 .04, d 5 1.0). Three themes emerged: the clinic play environment as a sanctuary, parental barriers
to intervention delivery, and tools for repeating learned lessons.
CONCLUSION. The parent-delivered intervention demonstrated preliminary evidence for feasibility and
effectiveness. Further research is warranted regarding appropriateness.

Wilkes-Gillan, S., Bundy, A., Cordier, R., & Lincoln, M. (2014). Evaluation of a pilot parent-delivered play-based intervention
for children with attention deficit hyperactivity disorder. American Journal of Occupational Therapy, 68, 700–709.
http://dx.doi.org/10.5014/ajot.2014.012450

Sarah Wilkes-Gillan, BAppSc(OT)Hons, is PhD


Candidate, University of Sydney, 75 East Street,
Lidcombe, New South Wales 2141, Australia;
D eveloping and evaluating psychosocial interventions for children is a complex
task. Establishing optimal intervention intensity and mode of delivery, the
interplay of parent–child characteristics, client acceptability, and effectiveness are
swil8454@uni.sydney.edu.au
all factors that contribute to the complexity (Campbell et al., 2007; Kazdin,
Anita Bundy, ScD, is Professor and Chair of 2007; Kazdin & Nock, 2003). For health care interventions to achieve a “gold
Occupational Therapy, University of Sydney, Sydney, standard,” evidence must be demonstrated in three areas: effectiveness (i.e., does
New South Wales, Australia.
the intervention work as intended?), feasibility (i.e., are adequate resources and
Reinie Cordier, PhD, is Associate Professor, School of funds available for implementation?) and appropriateness (i.e., what is the impact
Occupational Therapy and Social Work, Curtin University, of the intervention from the participants’ perspective? Evans, 2003). A gold-
Perth, Western Australia, and Faculty of Health Sciences,
standard approach has yet to be established for psychosocial interventions targeting
University of Sydney, Sydney, New South Wales, Australia.
the social skills of children with attention deficit hyperactivity disorder (ADHD).
Michelle Lincoln, PhD, is Professor and Deputy Dean, The social deficits of children with ADHD are well documented as a costly
Faculty of Health Sciences, University of Sydney, Sydney, and serious long-term problem (Doshi et al., 2012; Nijmeijer et al., 2008;
New South Wales, Australia.
Wehmeier, Schacht, & Barkley, 2010). Moreover, multiple systematic reviews
have demonstrated that social skills training, the most common approach, dem-
onstrates minimal effectiveness for children with ADHD (Antshel & Barkley,
2008; Pelham & Fabiano, 2008). In addition to limited effectiveness, the tra-
ditional approach of intensively teaching children socially acceptable behaviors in
controlled clinic groups lacks evidence of feasibility and appropriateness (Antshel
& Barkley, 2008).

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Previous Studies intensity and protocol would be difficult to replicate.
Moreover, the researchers could not unequivocally attri-
Psychosocial Interventions With Parent Involvement bute positive intervention outcomes to the friendship in-
Although parents are a natural and logical resource for tervention over other program components. Thus, further
promoting a child’s development, parents of children with research is required to evaluate effectiveness.
ADHD may require support to facilitate their child’s social–
Therapist-Delivered Play-Based Intervention
emotional development. Compared with parents of typically
developing children, parents of children with ADHD are In a previous study (Wilkes, Cordier, Bundy, Docking, &
known to experience increased stress, relational frustration, Munro, 2011), we applied the principles of a model for
and lower parenting self-esteem (Theule, Wiener, Tannock, play-based intervention for children with ADHD to develop
& Jenkins, 2012). and test a therapist-delivered intervention (Cordier, Bundy,
In recognition of the need to involve parents in psy- Hocking, & Einfeld, 2009). The therapist-delivered in-
chosocial interventions, three promising interventions using tervention involved each child with ADHD (n 5 14)
varying degrees of parent involvement have focused on inviting a typically developing playmate to attend seven
supporting parents of children with ADHD to promote weekly clinic-based sessions (Wilkes et al., 2011). To
their children’s friendships. First, Frankel, Myatt, Cantwell, motivate the children, the clinic was set up as an inviting
and Feinberg’s (1997) social skills training program in- playroom. A primary therapist worked closely with the
cluded child sessions involving behavioral rehearsal and children. Video self-modeling techniques (feedback and
coached interactions with peers. Coaches observed child- feed forward) were used; the therapist and children watched
ren’s peer interactions, delivered token reinforcement, and videotaped interactions from the previous week and had
imposed consequences for misbehavior (e.g., timeout). Con- a problem-solving discussion to anticipate the skills required
current parent group sessions focused on the reinforcement to make the subsequent play session enjoyable (e.g., “play
my friend’s game”). The therapist then modeled desired
of social skills at home. Although results for child outcomes
social interactions in the playroom by playing with the
demonstrated efficacy, neither feasibility nor appropriateness
children to promote cooperative play between them. Con-
were addressed explicitly. This approach has limitations,
currently, a second therapist worked with the parents,
among them that the intervention altered the natural
providing feedback on playroom observations and sug-
process of interpersonal learning that unfolds during peer
gestions for the application of techniques at home. The
interactions.
Test of Playfulness (ToP; Bundy, 2004) was used to ex-
Second, Mikami, Lerner, Griggs, McGrath, and
amine the children’s social play (i.e., play within a social
Calhoun (2010) trained parents as friendship coaches by
context involving peer-to-peer interactions).
teaching them to create social opportunities (play dates)
The intervention demonstrated efficacy in improving
and provide corrective feedback. Children were observed
the social play skills of children with ADHD (n 5 14, t 5
interacting in a playgroup with unknown peers on three
8.1, p 5 .01, d 5 1.5). Moreover, the children maintained
occasions for the purposes of parent training. The pilot
their gains 18 mo postintervention (n 5 5, Z 5 0.14, p 5
intervention demonstrated effectiveness in parent-rated
.89, d 5 20.4; Wilkes-Gillan, Bundy, Cordier, & Lincoln,
measures of social skills (ds 5 0.25–0.59), with parents
2014). However, as in the interventions described above,
reporting satisfaction with the intervention. However, no
evidence of feasibility and appropriateness is lacking. The
significant improvement was found in parent reports of cost of delivering an intervention requiring two therapists
play dates or in teacher reports of the child’s social skills. and the parent-identified need for support to refresh and
The researchers concluded that the intensive parent in- reinforce learned techniques over time (i.e., appropriate-
volvement required in delivering the intervention may limit ness) require ongoing development of the intervention
feasibility for some families and that a more intensive child (Wilkes-Gillan et al., 2014).
treatment component might improve effectiveness.
Third, in a summer-camp treatment program, Hoza,
Mrug, Pelham, Greiner, and Gnagy (2003) conducted
Development and Pilot of a
a friendship intervention, pairing children as “buddies.” Parent-Delivered Intervention
Findings demonstrated greater parent involvement (i.e., To address these needs, we developed an alternate version
more play dates scheduled with the buddy) and enhanced of the intervention that could be delivered by parents.
friendship quality as rated by teachers on a 5-point scale. Adjustments included reduced therapist involvement (e.g.,
However, feasibility is questionable because the intervention from two to one therapist per child and from seven to three

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clinic sessions) and the creation of a manualized parent difference 5 2.1 yr, SD 5 0.7). Playmates did not have
component consisting of an interactive DVD and a manual ADHD as defined by the CCBRS, and no concerns were
with play cards. We also created a low-budget website raised by parents or teachers about their development or
(http://ug2adhdfriendships.com) to assist parents in contacting behavior.
therapists and completing the intervention. The aims of
the current study were to examine the extent to which we Instruments
were able to retain effectiveness while offsetting resource Test of Playfulness. The ToP is a 29-item observer-rated
intensiveness and extending appropriateness in implementing instrument that is suitable for children ages 6 mo to 18 yr
the parent-based intervention. A secondary aim of the study and is administered using 15-min videorecorded samples
was to compare the feasibility and appropriateness of the of play (Bundy, 2004). It was used as a pretest, posttest, and
parent- and therapist-delivered interventions. To this end, follow-up measure to investigate children’s overall play
the following research questions were addressed: skills in the social context of peer-to-peer play interactions.
1. Effectiveness: Were the social play skills of children with Each item is rated on a 4-point scale to reflect extent, in-
ADHD improved after a parent-delivered intervention? tensity, or skillfulness. The ToP measures the concept of
In addition, were the social play skills of these children playfulness as a reflection of four elements: (1) relative in-
generalized to home and retained 1 mo after participation? ternal control, (2) relative freedom from unnecessary con-
2. Feasibility: What are the findings of a preliminary cost straints of reality, (3) relative intrinsic motivation, and (4)
analysis comparing resources used in both play-based framing (i.e., the ability to give and read social cues). The
interventions? ToP has evidence of excellent interrater reliability (data
3. Appropriateness: What were parents’ experiences of both from 96% of raters fit the expectations of the Rasch model;
play-based interventions? Brentnall, Bundy, & Kay, 2008), moderate test–retest re-
liability (e.g., intraclass correlation 5 .67, p < .01; Brentnall
Method et al., 2008), and construct validity (e.g., data from 93% of
items and 98% of people fit Rasch expectations; Bundy,
Research Design Nelson, Metzger, & Bingaman, 2001).
A purposive sample was used for this one-group pretest– Parenting Relationship Questionnaire. The Parenting
posttest study. Ethics approval was received from the Uni- Relationship Questionnaire (PRQ) is a standardized parent-
versity of Sydney’s Human Research Ethics Committee. All rated questionnaire with seven scales assessing parenting
participants gave informed written consent or verbal assent relationship factors that influence a child’s social–emotional
(i.e., children age <7 yr) before participating in the study. development (Kamphaus & Reynolds, 2006): Attachment,
Communication, Discipline, Involvement, Parenting Con-
Participants fidence, School Satisfaction, and Relational Frustration.
Families of children with ADHD who had participated in PRQ reliability coefficients for test–retest and internal
the therapist-delivered intervention 18 mo previously (Wilkes consistency ranged from .72 to .81, with evidence of mod-
et al., 2011) were invited to participate in the current study. erate construct validity (Rubinic & Schwickrath, 2010).
Because of time constraints (the school term was under way), Conners Comprehensive Behavior Rating Scales. The
only 5 of the original 14 families were available to participate CCBRS is a parent-rated questionnaire used as a screening
in the parent-delivered intervention. Children included in measure to confirm the presence or absence of symptoms
the current study were ages 6–11 yr and had a primary di- consistent with ADHD. Scores of >70 are above the clinical
agnosis of ADHD. cutoff. The CCBRS has good evidence for reliability and
Current ADHD symptoms were confirmed by parent validity: Cronbach’s a coefficients of .67–.97, 2–4-wk
ratings on the Conners Comprehensive Behavior Rating test–retest reliability of .56 to .96 (p < .001), interrater
Scale (CCBRS; Conners, 2008). Children continued to take reliability of .50–.89 (p < .001), and good discriminative
previously prescribed medications and did not commence validity (mean overall classification accuracy of 78% across
new therapies during the study. all forms; Conners, 2008).
The children with ADHD invited a typically developing
playmate to participate. To avoid unfamiliar playmates, who Procedure
might influence the results in unacceptable ways, the child Participants engaged in a 7-wk intervention involving
pairs were regular playmates and of similar age (maximum weekly home modules, three clinic-based play sessions,
age difference between play partners 5 3.1 yr, mean age and a follow-up visit. In each clinic-based session, play

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pairs were invited into a room that contained a one-way All videorecorded play sessions were scored by one of
mirror and that was set up to support social play (Cordier, five trained and calibrated raters. Raters were unaware of all
Bundy, Hocking, & Einfeld, 2010a). During two clinic aspects of the study. Each scored 5–10 videos. No rater scored
sessions, an occupational therapist (the first author, Wilkes- both pre- and posttest videos for a given child. The raters’
Gillan, or the third author, Cordier) played with the chil- scores were interpreted to be reliable because their goodness-
dren for 20 min, supporting engagement in child-initiated of-fit statistics were within the required parameters (mean
free play. The two therapists had developed and admin- square <1.4; standardized value £2; Bond & Fox, 2007).
istered the intervention techniques in a previous study The 1-mo follow-up included the therapist video
(Wilkes et al., 2011). To ensure uniformity, the therapists recording a 20-min play session at the child’s home. This
met regularly to review previous video footage of their video footage enabled scoring of the ToP. Within the
playroom interactions and to discuss the use of techniques. same week, individual semistructured interviews were con-
During the clinic sessions, the therapists promoted ducted with parents to investigate their perceptions of the
prosocial behaviors such as sharing and responding to intervention. A researcher not closely involved with the families
a playmate’s cues by engaging the children in mutually (the second author, Bundy) conducted the interviews. The
enjoyable, reciprocal social play, which often involved parent who was most involved in the interventions participated.
pretend play. The therapists also used key, consistent phrases Parents were asked for the number of home modules they
while in the playroom to promote cooperation between completed and their perspectives on both interventions (ther-
children—for example, “Let’s share our ideas about the apist and parent delivered) in relation to their child’s experi-
game.” Parents observed these sessions through the one- ence, their own experience, any benefits they or their children
way mirror. Afterward, the therapists discussed the session derived, and logistics that supported or hindered participation.
with the parents.
Parents provided a summative rating for their responses
To complete the home modules, parents received one-
by scoring both interventions on a 10-point scale ranging
on-one training at the clinic for 1 hr involving interactive
from 1 5 not enjoyable or beneficial or hard and 10 5 very
media (i.e., video footage, presentation, and website) and
enjoyable or beneficial or easy. Interviews were 30 to 50 min
a practical demonstration of how to use the DVD and
in length and were audiorecorded and transcribed verbatim.
manual resource. Modules involved parents reading a
prescribed manual chapter and watching a corresponding Data Analysis
DVD episode with their child and then facilitating a play
Effectiveness: Child Outcomes. Children’s raw ToP
date at home. Parents were given a set of three colored play
scores were entered into an existing database containing
cards to use as visual cues when discussing the DVD and
when giving their child feedback on their social interactions scores of children with ADHD and typically developing
before, during, and after the play date. The green card was children (N 5 378). The Facets Rasch analysis program
used to convey “Great play! Keep going!”; the red card, to (Version 3.70.1; Linacre, 2012) was then used to convert
convey “Stop! Let’s think about what happened”; and the ToP raw scores into interval-level scores. Rasch analysis
purple card, to prompt discussion of “three things to re- produces an overall measure score for each person, similar
member while we play.” Twelve modules were available; to a standard score (Bond & Fox, 2007).
each addressed interactional difficulties experienced by Measure scores produced by Facets were then entered
children with ADHD. Further information on the mod- into IBM SPSS Version 19 (IBM Corporation, Armonk,
ules is reported in Wilkes-Gillan, Bundy, Cordier, and NY). Because of the small sample size, Wilcoxon signed-
Lincoln (in press). The therapist prescribed three modules rank tests for related samples were calculated to compare
during Weeks 1–2 and a new module weekly thereafter. mean ToP scores from two points in time, before and after
A low-budget website was designed for contact between the parent-delivered intervention and preintervention to
parents and the therapist (http://ug2adhdfriendships.com). 1-mo follow-up (Siegal & Castellan, 1988). Significance
Parents used the website to access an electronic version of was set at p < .05. Cohen’s d values were calculated to
the material and to log the completion of their weekly examine effect size, interpreted as small, ³0.20; medium,
activity, notifying the therapist to prescribe the next ³0.50; or large, ³0.80 (Cohen, 1992).
module. However, parents preferred phone contact dur- Feasibility: Cost Analysis. To evaluate intervention fea-
ing school hours. The therapist prescribed modules on sibility, we conducted a cost analysis. Program costs of both
the basis of the child’s social play needs as reflected in the therapist- and parent-delivered interventions were recorded
baseline ToP scores and ongoing weekly phone discussions to allow a comparative cost analysis. Costs were categorized
with parents. as therapist or material costs (Creese & Parker, 1994). We

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converted therapist hours into monetary amounts (e.g., is reported in Table 1. Additionally, descriptive information
hourly rate multiplied by intervention hours). on parent–child relationships was collected using the PRQ
Appropriateness: Parent Responses. Analysis regarding (see Table 2).
intervention appropriateness involved parent interview
data. Thematic analysis by means of an open and axial Effectiveness: Overall Improvements in Social
coding process (Strauss & Corbin, 1990) was used to Play Skills
analyze interview responses. Each transcript was broken Wilcoxon signed-rank tests for related samples indicated no
down into discrete parts of text and then coded manually. difference before and after intervention (Z 5 1.48, p 5
Data were then compared to form subthemes and then .14). However, pretest to 1-mo follow-up findings
core themes. Data interpretation was checked using peer demonstrated significant improvement (Z 5 2.02, p 5 .04;
review processes (Strauss & Corbin, 1990). Themes were see Table 3).
reviewed by a research group of doctoral candidates. The
first and second author then reexamined the themes to Feasibility: Cost Analysis
reach consensus. The means of parents’ summative ratings Results from the preliminary cost analysis indicated that
on the 10-point scale were also calculated. the parent-delivered intervention was less costly. More
information is presented in Table 4.
Results
Recruitment yielded 5 boys with ADHD; 4 mothers and 1 Appropriateness: Parents’ Summative Ratings
father also participated. Regarding child and parent de- Parents’ mean responses indicated a higher preference
mographic variables, the participants differed from the original for the therapist-delivered intervention (see Table 4).
group on only one variable: The children presented with Thematic analysis revealed three core themes: (1) the
significantly lower levels of inattention (Z 5 2.03, p 5 .04) clinic play environment as a sanctuary, (2) parental barriers
as measured by the CCBRS. All participants were to intervention delivery, and (3) tools for repeating learned
White. Information about child and parent participants lessons.

Table 1. Participant Demographics


Participant Playmate
Characteristic (N 5 5) (N 5 5)
Parent variables
Mean age, yr (SD) 45.4 (7.2) 44.2 (5.0)
Education level, %
University 60 60
High school 40 40
Primary caregiver’s occupation not requiring a university degree, % 80 80
Child variables
Mean age (SD) 8 yr, 9 mo (1 yr, 6 mo) 8 yr, 7 mo (1 yr, 7 mo)
Gender, male, n 5 4
ADHD symptomatology (mean CCBRS scores)
Hyperactivity 73.20a 54.60
Inattention 75.80a 56.60
Conduct behavior 67.40 53.20
Oppositional behavior 79.80a 65.00
Generalized anxiety disorder 75.40a 58.40
Academic difficulties 72.20a 54.40
Social problems 75.00a 74.00b
ADHD subtypes, n
Predominantly inattentive 1 —
Predominantly hyperactive and impulsive 2 —
Combined subtype 2 —
Medication taken for ADHD, n 4 —
Sibling as playmate, n 4 —
Note. — 5 not applicable; ADHD 5 attention deficit hyperactivity disorder; CCBRS 5 Conners Comprehensive Behavior Rating Scales.
a
Above the clinical cutoff of 70. bPlaymates mean score was above the clinical cutoff (>70) on social problems (a non–ADHD symptom subscale), supporting the literature
postulating that playmates of children with ADHD may mirror the negative behaviors exhibited by the child with ADHD (Cordier, Bundy, Hocking, & Einfeld, 2010b).

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Table 2. Parent–Child Relationship Information as Measured by the Parenting Relationship Questionnaire (N 5 4)
Scale Scale Description Mean T Score (SD)a
Attachment Affective and cognitive relationship between parent and child 37.0 (13.3)
Communication Quality of information exchanged between parent and child 34.8 (9.4)
Discipline Application of consistent consequences for misbehavior 40.5 (10.8)
Involvement Level of parent participation in activities with the child 51.0 (9.9)
Parenting confidence Confidence and comfort in the parenting process and decision making 28.8 (7.8)
School satisfaction Parent belief that the school is meeting the child’s needs 42.0 (4.5)
Relational frustration High levels of stress when relating to or controlling the child 76.5 (9.4)
Note. SD 5 standard deviation.
a
T scores are interpreted as follows: 10–30, lower extreme; 31–40, significantly below average; 41–59, average; 60–69, significantly above average; 701, upper
extreme. The 4 parents who completed the measure had mean scores significantly below average on three subscales and were in the lower or upper extreme range
on two subscales.

The most frequently mentioned theme was that the 4. Need for further support to overcome these barriers.
clinic play environment was a sanctuary. Parents valued
The final core theme to emerge was that the parent-
the experience of seeing their child enthusiastically en-
delivered intervention equipped parents with tools for
gaged in prosocial interactions:
repeating learned lessons:
There [the clinic playroom], he is himself—he’s having
Even if we get to the end of our involvement with the
a ball. . . . It’s about an environment where he’s subtly
program, we can keep using it [DVD, manual, and play
learning about himself. He wasn’t angry or withdrawn. . . .
cards] . . . to get the best value. . . . We needed to repeat
It was just fantastic; he was a real team player. . . . Seeing and engage with the language of the visits and the
your child at play, I think that’s really important, espe- lessons learned. (Parent 3)
cially when you have a child like mine that has problems
with socializing. (Parent 5) These tools helped parents overcome barriers and engage
in positive parent–child interactions, allowing them to
Parents further noted that clinic visits enabled positive support their child’s social skills:
parent–child experiences. As Parent 4 noted, “He was en-
gaged, and I didn’t have to battle him to be engaged— I thought, “It’s to benefit my child—we have to do
it.” . . . There were lots of things I’d forget . . . that’s why
that’s huge benefits for me . . . in terms of managing my
it’s good to have the manual. I think in any of the
stress and how difficult it can be with him.” Parent 1
programs, the parent has to be involved. (Parent 3)
highlighted the opportunities for positive communication
through a “common language for talking about specific, Parent 2 observed,
appropriate strategies for good play.” I might get them [intervention play cards] out, especially
A contrasting core theme, pertaining to when the if they are playing well. . . . I’ve not wanted to break the
parents delivered the intervention, was parental barriers nice play with talking, so I’ve grabbed the little green
to intervention delivery. This theme emerged from four card and gone up to him [and shown him the card], so
subthemes: he can smile at me and go, ‘Oh, that’s good.’” (Parent 2)
1. Demands of family life: “Besides the extra spelling,
Table 3. Scores on the Test of Playfulness and Effect Sizes of the
speech, and messages, he got to the point where he Parent-Delivered Intervention on Participants’ Social Play
just didn’t want me around. . . . It was another thing Outcomes
I had to motivate him to do, which got really hard” Effectiveness M (Range)a SD Cohen’s d b Effect Sizec
(Parent 5). Pretest to posttest 11.1 0.5 Medium
2. Challenging child relationships: “It’s difficult to engage Pretest: Session 1 69.0 (53.1–79.4)
him. . . . I didn’t persist, either; part of that was I’d run Posttest: Session 7 74.3 (55.1–83.3)
out of energy to do it and manage everything else. Pretest to 1-mo 9.6 1.0 Large
follow-up
He’s quite a challenging child” (Parent 4). Pretest: Session 1 69.0 (53.1–79.4)
3. Perceived skills: “This was well outside my skill set. . . . Follow-up 78.6 (71.5–83.4)
I’m a parent” (Parent 2). One skill described was Note. M 5 mean; SD 5 standard deviation.
a
“scheduling it in around everything else that’s going Mean scores and standard deviations were derived from interval-level measure
scores. bCohen’s d effect sizes were calculated as follows: group (mean posttest 2
on . . . mobbing [moving] through slowly and sporad- mean pretest)/pooled SD for group measure scores. cEffect sizes were interpreted
ically” (Parent 1). as large (³ 0.80), medium (³ 0.50), or small (³ 0.20; Cohen, 1992).

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Table 4. Comparison of the Feasibility and Appropriateness of the Therapist-Delivered and Parent-Delivered Play-Based Interventions
Type of Evidence Therapist-Delivered Intervention Parent-Delivered Intervention
Feasibility
Summary of resources per child, A$
Estimated therapist cost per childa 578.00 (17 hr · 2 therapists) 153.00 (4.5 hr · 1 therapist)
Materials cost per childb 127.50 127.00
Total costs per child 705.50 280.00
Appropriateness
Parent self-reported compliance With home play tasks With home modules
Weekly activities completed (SD) 66% of 6 (1.9) 70% of 8 (2.9)
Mean parent summative ratingsc (SD)
Child’s experience 9.5 (0.6) 6.6 (2.2)
Parent’s experience 8.3 (2.5) 6.0 (1.6)
Benefits to child 8.1 (1.6) 7.1 (2.1)
Benefits to parent 8.4 (1.6) 5.9 (1.1)
Logistics 7.6 (2.9) 6.3 (2.1)
Mean overall rating 8.4 6.4
Note. A$ 5 Australian dollars; SD 5 standard deviation.
a
Therapist costs were based on the Australian New South Wales Health Service Health Professionals (State) Award wage for a Level 2 occupational therapist (A$34
per hour). Therapist hours include face-to-face time (clinic intervention sessions) and non-face-to-face time (videomodeling or phone consultations). bMaterials
included toys, intervention DVD and manual, and blank DVDs. Equipment and building costs (i.e., laptops, room hire, electricity) and parent time were not included.
c
Parents provided summative ratings of the interventions using a 10-point ordinal scale, with 1 5 not enjoyable or beneficial or hard and 10 5 very enjoyable or
beneficial or easy. When parents nominated two scores (e.g., “between 5 and 6”), an average was calculated (i.e., 5.5).

Discussion et al., 2010; Wilkes et al., 2011). Although preliminary,


these results hold promise, even though psychosocial in-
We implemented and evaluated the results of a pilot parent-
terventions targeting the social impairments of children
delivered, play-based intervention aimed at improving the
with ADHD have previously demonstrated minimal ef-
social play skills of children with ADHD and compared
fectiveness (Antshel & Barkley, 2008; Antshel & Remer,
results with those of a previously conducted, intensive
2003; Pelham & Fabiano, 2008).
therapist-delivered intervention (Wilkes et al., 2011).
We aimed to refine the initial pilot of the intervention Feasibility
(Campbell et al., 2007) and adopted an evidence-based
Although the parent-delivered intervention costs were less
evaluation framework (Evans, 2003). We invited previous
than those associated with the therapist-delivered in-
participants from the therapist-delivered intervention to tervention, as did Mikami et al. (2010) we found that an
participate in the current intervention. Both interventions increase in parent involvement compromised feasibility,
were in the context of dyadic peer play and involved highlighting the interconnected nature of intervention
varying degrees of video self-modeling, peer and therapist effectiveness, feasibility, and appropriateness. This com-
modeling, and parent involvement. promised feasibility was demonstrated by a lower effect
size in the short term (i.e., pre–post intervention) paired
Effectiveness
with increased gains at follow-up as parents continued the
The pilot parent-delivered intervention demonstrated pre- intervention strategies with their child. Parent time was
liminary effectiveness in improving the social play skills of not considered in the cost analysis; however, it may have
children with ADHD (d 5 0.5, medium effect size), which had feasibility implications for parents by decreasing parents’
increased over time (pretest to 1-mo follow-up d 5 1.0, engagement and the intensity with which they completed
large effect size). These results are similar to the previously intervention home modules, in turn contributing to reduced
conducted therapist-delivered intervention (d 5 1.5, large effectiveness in the short term.
effect size; Wilkes et al., 2011), strongly supporting the
combined use of these techniques as a potentially effective Appropriateness
means to develop the social play skills of children with Parent responses indicated greater satisfaction with the
ADHD. Moreover, these results support previous research therapist-delivered intervention. As expected, the context
demonstrating that intervention outcomes (medium to large of play increased intervention appropriateness for children
effect sizes) are better generalized with increased parent in- by providing them with ample and enjoyable opportunities
volvement (Frankel et al., 1997; Hoza et al., 2003; Mikami to regulate their emotions and develop prosocial skills.

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However, the degree of enjoyment that parents experienced because participants had received the therapist-delivered
in observing their child play was somewhat unexpected. In play-based intervention 18 mo previously. Further re-
accordance with the play literature, parents discussed the search on the parent-delivered intervention is required.
benefits of observing their child succeeding at cooperative This study provides preliminary evidence that the
interactions (Ginsburg, 2007). They identified play as a parent-delivered intervention, characterized by increased
valuable process that presented them with opportunities parent involvement, may be feasible and effective. Intervention
to support and communicate positively with their child modifications could improve appropriateness and in turn
and fostered positive parent–child interactions (Ginsburg, enhance effectiveness. Further intervention development
2007; O’Neill, Rajendran, & Halperin, 2012). should target the following: decreasing the intensity of in-
As the intervention progressed, we suspected that some tervention delivery for parents, increasing therapist support,
parents may have benefited from additional clinic visits and and trialing the intervention with larger numbers of families.
therapist support. Reflected in parents’ interview responses Longer-term outcomes should be evaluated to establish
were a constellation of barriers to intervention delivery, which the optimal intervention intensity and a balance in feasi-
resulted in them moving “slowly and sporadically” through bility that reduces the resources required while maintaining
the parent-delivered intervention. These findings highlight effectiveness and appropriateness. Additionally, continued
the impact of intervention appropriateness on effectiveness. collection and evaluation of parent–child relationship data
Promoting positive parent–child interactions is likely are important. Such information could help future re-
foundational to successfully engaging and assisting parents of searchers determine the allocation of families to differing
children with ADHD in efforts to facilitate their children’s intervention duration and modes of delivery. We postu-
social competence. Previous research has indicated that chil- late that because of the heterogeneous nature of ADHD,
dren with ADHD are at risk of continuing difficulties when varying severity of social impairments, and the complex
negative parent–child interactions are present and when pa- nature of parent–child relationships, balanced use of both
rental confidence is low (Fischer, Barkley, Fletcher, & Smallish, therapist- and parent-delivered interventions may ulti-
1993; Lifford, Harold, & Thapar, 2008). These findings mately be required to optimize intervention feasibility,
highlight the importance of intervention appropriateness effectiveness, and appropriateness. Larger-scale studies are
to optimize parents’ engagement in the treatment process. required to investigate these possibilities and to investigate
Two factors may have influenced parents’ preference variables that may influence intervention outcomes. More-
for the therapist-delivered intervention. First, 18 mo before over, larger scale studies will identify whether an intervention
this study, the parents were involved in a therapist-delivered set in the context of play yields the gold-standard approach to
intervention that placed significantly fewer demands on addressing the social impairments of children with ADHD.
parents. Second, this group of parents experienced par-
ticularly high levels of relational frustration and low levels
of confidence in their parenting ability as measured by
Implications for Occupational
the PRQ (see Table 2; Rubinic & Schwickrath, 2010; Therapy Practice
Theule et al., 2012). This second factor is reflected in the The findings of this study have the following implications
qualitative subthemes of parental barriers to intervention for occupational therapy practice:
delivery: demands of family life, challenging relationship • Parents of children with ADHD may require support
with child, perceived skill set, and need for further support. to facilitate their child’s social–emotional development.
We therefore postulate that parent–child relationship var- • Play as a medium for intervention can increase interven-
iables may have reduced intervention appropriateness for tion appropriateness and provide an enjoyable and sup-
this particular group, thus possibly limiting short-term portive environment for both children and their parents.
effectiveness. In addition to the level of difficulty experienced • A play-based intervention may yield an effective, fea-
by the child, parent–child relationship factors may predict the sible, and appropriate approach for addressing the so-
level of intervention intensity and mode of delivery needed to cial impairments of children with ADHD. s
ameliorate the social difficulties of children with ADHD.
Acknowledgments
Limitations and Future Research We extend our gratitude to the participating families, to the
The small, nonrandomized sample limits generalization of members of Mosman Rotary Club for providing financial
results to the broader population of children with ADHD. assistance, and to the occupational therapy students who
Additionally, a carryover effect may have been present assisted in the development of the DVD and manual.

The American Journal of Occupational Therapy 707


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We also acknowledge the Australian Postgraduate Award of Clinical Nursing, 12, 77–84. http://dx.doi.org/10.1046/
scholarship awarded by the Australian government. j.1365-2702.2003.00662.x
Fischer, M., Barkley, R. A., Fletcher, K. E., & Smallish, L.
(1993). The adolescent outcome of hyperactive children:
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