Australian Occupational Therapy Journal (2009) 56, 332–340 doi: 10.1111/j.1440-1630.2009.00796.x

Blackwell Publishing AsiaResearch Article

A model for play-based intervention for children with ADHDReinie Cordier,1 Anita Bundy,1 Clare Hocking2 and Stewart Einfeld3

1Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia, 2School of Rehabilitation and Occupation Studies, AUT University, Auckland, New Zealand, and 3Faculty of Health Sciences, Brain and Mind Research Institute, The University of Sydney, Sydney, New South Wales, Australia

Background/aim: The importance of play in the socialdevelopment of children is undisputed. Even though childrenwith attention-deficit hyperactivity disorder (ADHD)experience serious social problems, there is limited researchon their play. By integrating literature on ADHD withliterature on play, we can postulate how play is influencedby the characteristics of ADHD. These postulations enabledus to propose a theoretical model (proposed model) to depictthe interactive process between the characteristics ofADHD and factors that promote play. This paper presentsthe revised model and principles for intervention based onthe results of a study investigating the play of children withADHD (reported elsewhere).Methods: We tested the proposed model in a study comparingtwo groups of children (n = 350) between the ages of 5 and11 years. One group consisted of children diagnosed withADHD (n = 112) paired with playmates (n = 112) whowere typically developing; the control group consisted oftypically developing children paired with typically develop-ing playmates (n = 126). The Test of Playfulness wasadministered, and the model was revised in line with thefindings.Results and conclusions: The findings suggest difficultiesin the social play and lack of interpersonal empathy in theplay of children with ADHD. We draw on the revisedmodel to propose preliminary principles for play-basedinterventions for children with ADHD. The principles

emphasise the importance of capturing the motivation ofchildren with ADHD, counteracting the effects of lack ofinterpersonal empathy, and considerations for includingplaymates in the intervention process.

KEY WORDS child development, developmental disorders,mental health, paediatrics, play.

IntroductionAlthough there are vast amounts of research on attention-deficit hyperactivity disorder, and to a lesser extent playof children with ADHD, there is surprisingly littleresearch on the sequelae to ADHD conducted in thecontext of play. This is particularly unexpected as pro-fessionals working with children with ADHD commonlyuse play to explore behavioural and social difficultiesand as a medium for intervention (Barkley, 2006). Whatlimited research there is on the play of children withADHD suggests that children with ADHD engage in lessassociative and cooperative play compared with typicallydeveloping peers (Alessandri, 1992). Leipold and Bundy(2000) found that children with ADHD are less playful.In addition, Alessandri found that children with ADHDstruggle to transition between play activities. Melnickand Hinshaw (1996) established that children withADHD demonstrate more negative behaviours in play(e.g. disruptions, rule violation).

This paper presents the proposed theoretical modeland a revised model of the play of children with ADHDbased on research findings. A proposed model wasconstructed by integrating literature on ADHD withliterature on play and postulating how the characteristicsof ADHD may influence play. This has enabled us toconstruct a model that depicts the interactive processbetween the characteristics of ADHD and factors thatpromote play (play enablers). This proposed model isbased in an accepted definition of play: a transactionwith the environment that is intrinsically motivated,internally controlled, and free of many of the constraintsof objective reality (e.g. Skard & Bundy, 2008). In keepingwith Bateson (1971, 1972), the proposed model also

Reinie Cordier BSocSc Hons (Clin Psych), MOccTher, PhDCandidate. Anita Bundy ScD, OTR, FAOTA; Chair ofOccupation and Leisure Sciences. Clare Hocking PhD,MHSc(OT); Associate Professor. Stewart Einfeld MD,DCH, FRANZCP; Chair, Senior Scientist.

Correspondence: Anita Bundy, Faculty of Health Sciences,The University of Sydney, PO Box, 170, Lidcombe, Sydney,NSW 1825, Australia. Email: a.bundy@usyd.edu.au

Accepted for publication 9 March 2009.

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considers skills related to setting the play frame (i.e.reading and responding to cues). Using the Test ofPlayfulness (ToP) (Bundy, 2004) which operationalisesthis definition of play, we set out to construct the model.

The theoretical model is developed on the assumptionthat play is important. The importance of play has beendescribed by many play authors (Sutton-Smith, 1997;Parham, 2008). Much of children’s early learning isachieved through play; their physical and socioemotionaland intellectual development is dependent on the qualityof their play (Parham). Play is very often a social experience(Sutton-Smith). In play, children imitate social actionsand learn to interact (Aeri & Verma, 2004). By modellingadults, infants enjoy playful intimacy and gain experiencein social reciprocity (Bandura, 1989). They develop morecomplex prosocial behaviours such as praising, conversing,smiling, sharing and waiting for a turn (Power, 2000).Furthermore, social play promotes active peer engagementand social competence, which are regarded as ‘cornerstone’skills that lead to the development of cognitive, socialand cultural competence (Strain & Danko, 1995).Through play, they imitate adults, learn how to solveproblems, work cooperatively with others and developvoluntary plans (Parham). It is therefore not surprisingthat a child’s playfulness or flexibility of approach hasbecome a key determinant of whether or not an activityis play (Skard & Bundy, 2008).

Figure 1 illustrates the proposed model relating thecharacteristics of ADHD to play. The centre of the modelrepresents the play transaction and shows that anyreduction in the elements of playfulness (due to thepresence of ADHD characteristics) needs to be offset byplay enablers. The proposed model also reflects thatthe actual ToP items on which children with ADHDperformed significantly better or poorer compared withtypically developing children is still unknown (thus ToPitems are denoted with a question mark). Individualcharacteristics of play are represented in superscriptsthroughout the narrative description of this model; thesematch the numbers in the columns marked ‘Linkages inLiterature’ and ‘Play Enablers’ in Fig. 1. The proposedmodel also is described briefly below in relation tothe four elements of playfulness: intrinsic motivation,internal control, freedom to suspend reality and settingthe play frame.

Intrinsic motivation and ADHDThe motivation to play rests on the premise of a fear-freeenvironment1 (Moyles, 1989), where tasks are self-selected2,and players experience success much of the time3

(Malaguzzi, 1998). Furthermore, the impetus for the player’sinvolvement stems more from the activity itself thanfrom an external reward4 (Bundy, 2004). The presence ofintrinsic motivation can be observed, in part, in theextent to which play is all absorbing and the player getscompletely caught up in the play transaction5 (Bundy;Csikszentmihalyi, 1990).

The developmentally inappropriate level of inattentionthat characterises ADHD is highly situational (Schachar,1991) and is heightened when tasks are unappealing,boring or offer little immediate reward6 (Dinklage &Barkley, 1992). Children who lack motivation for a taskmay be unwilling or unable to maintain the effortrequired to sustain attention on that task (Barkley, DuPaul& McMurray, 1990). Consequently, researchers havesuggested that motivational rather than attentionaldeficits may explain the behavioral inattention seen inchildren with ADHD7 (Diamond, 2005; Dinklage & Barkley).

Apparent hyperactivity is also heightened duringactivities with little intrinsic appeal (Wood, 1995). Childrenwith ADHD may appear hyperactive because they failto regulate their activity according to situation or taskdemands and constantly move from one task to another8

(Barkley et al., 1990; Dinklage & Barkley, 1992). Postulation:Children with ADHD who experience decreased motiva-tion to engage in certain play activities may be unwillingor unable to maintain the effort to sustain attention andconsequently move frequently between tasks (due tosymptoms of inattention and hyperactivity), therebycausing children with ADHD to be less playful.

Internal control and ADHDMalaguzzi (1998) emphasised the importance of allowingchildren the control to self-initiate tasks as a means ofsustaining intrinsic motivation. Internal control thereforeserves as a mediator for intrinsic motivation9 (Neumann,1971). Where activities are child-initiated, such as inplay, children are more able to control the outcomes ofan activity10 (Skard & Bundy, 2008). Thus players arelargely ‘in charge of’ their actions and at least someaspects of the activity’s outcome11. In short, internalcontrol enables individuals to be whomever they desire,and to control material things and make them do whatevertheir competence allows12 (Connor, Williamson & Seipp,as cited in Bundy, 2004).

Self-control, defined as the exercise of internal controlover one’s own actions (Zimbardo, 1985), keeps in checkimpulsive, irrational and unacceptable behaviours (Dennis,1996). Children with ADHD have inadequate self-control(due to deficient self-regulation and observed as hyperac-tive and impulsive symptoms), may cause children withADHD to feel they are not in control13 (Barkley, 1997).Postulation: The decreased control over activities and theiroutcomes (due to hyperactive and impulsive symptoms)will cause children with ADHD to be less playful.

Suspension of reality and ADHDFreedom to suspend reality means that the player is notbound by unnecessary constraints of reality and is thusable to choose how close to objective reality a transactionwill be14 (Bundy, 2004). The usual meanings of objects nolonger apply15. The situation is under the control of theplayer who has the power to orchestrate it in such a wayas to influence the outcome16,17 (Dennis, 1996). Postulation:

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FIGURE 1: Proposed model.

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The ability to suspend reality depends on taking control.Children with ADHD who have reduced internal controlwill have a decreased ability to suspend reality andtherefore be less playful.

Framing and ADHDBateson (1971, 1972) described the player’s ability to giveand respond to social cues as ‘framing’ the context ofplay18. Responding to playmates’ cues requires anunderstanding of social rules19 and gives players thepossibility to support their playmates20 (Bundy, 2004).The social behaviours of children with ADHD are seenas abnormal because they often are inappropriate fortask or environmental demands21 (Barkley, 2006; Fadely& Hosler, 1992). Evidently, the cumulative effect ofimpulsivity, hyperactivity and inattention leads to areduction in social functioning (Barkley et al., 1990;Schachar, 1991; Wood, 1995). Postulation: The decreasedability of children with ADHD to give and respond tosocial cues will cause them to be less playful.

The proposed model described in Fig. 1 provides atheoretical view of how play might be influenced by thesymptoms of ADHD. We tested the proposed model in astudy comparing two groups of children (n = 350)between the ages of 5 and 11 years. One group consistedof children diagnosed with ADHD (n = 112) paired withplaymates (n = 112) who were typically developing; thecontrol group consisted of typically developing childrenpaired with typically developing playmates (n = 126).

We administered the ToP (Bundy, 2004) in an environmentdesigned to be particularly appealing. The details of thestudy are presented elsewhere (Cordier et al., forthcoming).The purpose of this paper is to present the revised modelas it was adjusted based on our findings and to presentpreliminary principles for play-based interventions forchildren with ADHD derived from our findings.

Revised modelThe model presented in Fig. 2 depicts the play profile ofchildren with ADHD and their playmates. This revisedmodel is discussed under four subheadings: primarysymptoms of ADHD, social dimensions of play, inter-personal empathy and summary of overall differencesbetween the proposed model (informed by literature)and the revised model (informed by research findings).

Primary symptoms of ADHDIn contrast with our postulations, none of the ToP itemsthat related directly to the primary symptoms of ADHDdiffered significantly between children with ADHD andtypically developing children, suggesting that the primarysymptoms of ADHD (inattention, hyperactivity andimpulsivity) did not account for the difficulties experiencedby the children with ADHD with regard to play. Bydefinition, six ToP items relate directly to the primarysymptoms of ADHD. See Table 1 for a summary of thedescriptions of the ToP items and their relationship to

TABLE 1: Primary symptoms of attention-deficit hyperactivity disorder (ADHD) and Test of Playfulness (ToP) item

Meaning of low scores ADHD DSM-IV criteria* Interpretation using the ToP

‘Initiate new activities (1)’ — players attempt to initiate play destructively or do not try to initiate activity that can be readily identified 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 organising 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 purposefully selected activity or wanders aimlessly or participates in a non-focussed activity.

Inattention: Often has difficulty sustaining attention in tasks or play activities.

Players may often have difficulty focussing on an activity, due to inattention and hyperactivity.

Hyperactivity: Often has difficulty playing quietly.

‘Intensity of engagement (22)’ — players have great difficulty concentrating on the activity.

Inattention: Often has difficulty sustaining attention in tasks or play activities.

Players may interact superficially due to inattention and hyperactivity.Hyperactivity: Often has difficulty playing

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.

*Excerpts from the DSM-IV criterion for ADHD (American Psychiatric Association, 2000).

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FIGURE 2: Revised model.

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the characteristics of the primary symptoms of ADHD.This finding might be explained by the play environmentin which data were collected, which was designed to beparticularly appealing in order to increase the chancesthat play occurred. The environment where data weregathered for children with ADHD was a playroom setup specifically for the study in a clinical setting wherethe children with ADHD came regularly for assessmentor intervention. The play environment for children in thecontrol group was a designated play area at the respectiveschools that children in the control group attended. Theplay environment was designed to be appealing in orderto increase chances for spontaneous and intrinsicallymotivated play behaviour to occur. Apparently a veryappealing environment does indeed offset the primarysymptoms of ADHD (Diamond, 2005).

Social dimensions of playThe children with ADHD had difficulty with many butnot all ToP social items (i.e. items that require socialinteraction to be scored), thus underscoring their socialdifficulties. While there was no difference in the proportionof time children with ADHD and typically developingchildren interacted with playmates, the intensity ofthat interaction was significantly less for children withADHD and they were less skilled at social play than thechildren in the control group. Taken together, thesefindings suggest that children with ADHD seek out socialinteraction as much as typically developing children butstruggle as the transaction develops, perhaps in partbecause they have difficulty responding effectively totheir playmates’ cues.

Interpersonal empathyOur results suggest that children with ADHD havedifficulty identifying the emotional states of theirplaymates, taking on their perspectives and sharing theiraffective responses (Cordier et al., forthcoming). Thepattern of observations that occurred in the context ofsocial play suggests a developmentally inappropriatelack of empathetic responding. As a continued reflectionof their diminished empathy, children with ADHDseemed to lack insight into the importance of reciprocity;thus the play frame often was disrupted. These findingsare particularly important because lack of empathy mayhave significant implications for prosocial development,particularly as play is the milieu within which childrendevelop social skills and form peer relationships (Dodge,1983). In the extreme, diminished empathy could haveadverse implications for the development of moralityand can potentially lead to antisocial behaviour (Barkley,1995, 1997).

Summary of overall differences between the proposed and revised modelsAlthough very similar to the proposed model, the dataled to four modifications in the revised model. First, theintrinsic nature of the motivation of children with ADHD

was not affected as had been postulated originally. While,as expected, internal control was severely affected,surprisingly the ability to suspend the unnecessaryconstraints of reality was not. This was due to highscores on mischief/teasing which have offset low scoreson pretend play. Finally, the children’s ability to frameplay by giving and responding to play cues was affected,but not as severely as anticipated; they were very able togive cues but had difficulty responding. The graphicrepresentation of the revised model of the interactiveplay transaction of children with ADHD compared withtypically developing children is depicted in Fig. 2.

Using the revised model to plan interventions for children with ADHDSome of what we learned about the play of children withADHD will enable the development of useful guidelinesfor a play-based therapy structure. If a model for play-basedtherapy is employed as an adjunct therapy for ADHD,therapists need to consider the following.

Intrinsic motivationOur findings clearly suggest that addressing themotivational aspects of play could offset the primarysymptoms of ADHD in a free-play context. Thereforein planning interventions for children with ADHD,one of the primary considerations should be to capturechildren’s intrinsic motivation. As such, considerationshould be given to setting up a physically and emo-tionally safe environment and providing opportunitiesto choose or develop activities that reflect the thingsthe child is seeking through play. Capturing children’smotivations ensures that they engage in the activitiesfor the sheer pleasure of being involved rather thanfor a specific outcome; it also increases their abilityand willingness to sustain attention and to maintain playthemes.

EmpathyThe strength of our findings regarding the lack ofinterpersonal empathy that was characteristic of the playof children with ADHD suggests the need to considerthe process of decentering when planning interventionsfor children with ADHD. Specifically, features such asdiscriminating and identifying the emotional states ofplaymates, taking on playmates’ perspectives or roles,and evoking shared affect are important. Interventionsaimed at decentering that have proved effective includeusing nascent collective symbolism where playmatespractice imitation with same symbolic meaning to actionsduring pretend play (e.g. both players know that handingeach other pieces of paper represent payment) (Hoffman,2001) and collective pretend play which involves sharedcooperative activities and joint creation of characters(Stambak & Sinclair, 1993).

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Ironically, a very good example illustrating collectivesymbolism in pretend play came from a play session weobserved between a boy with ADHD (Evan) and hisfriend (Troy). Their play transaction stood out as excep-tionally creative and complex and it was characterisedby finely tuned perspective-taking. The boys created aworld of princes and dragons out of simple toys andsand (collective symbolism — joint creation of characters).They alternated taking the lead in creating theirimaginary world, sometimes by verbally announcing anew character with a short description: ‘This can be theprince who has gone on a journey to find the spiked-backdragon’, pointing to an oddly shaped piece of wood. Onother occasions they seem to follow each other intui-tively, knowing that burying the dragons in the sandmeant that the princes had secured yet another victory(collective symbolism — imitation with same symbolicmeaning to actions). So absorbed were they in their playthat when the 20-min play session was finished, theypleaded for more time to kill off the dragons who threat-ened their kingdom. Upon enquiry, the parent of thechild with ADHD indicated that the boys play for hoursand it is often difficult to get them to go to bed whenthey are having a sleep-over.

Studying those children with ADHD whose play is notaffected is useful as it could provide us with importantclues in developing interventions for children withADHD whose play is affected. What then enables a childwith ADHD to be so skillful at play while most struggleto keep the play transaction flowing? The answer isunclear given that we did not observe the ‘Evan’ playingwith another playmate. ‘Evan’ may simply be a goodplayer. However having a good friend and playmate alsoseemed key. The mother described an intimate friend-ship lasting many years, which endured even though‘Evan’ had experienced many challenging times in hisyoung life as a result of difficulties associated withADHD. ‘Troy’ was always there to take his mind off thingswhen the going was tough at school.

How do we foster friendships for children withADHD? Using social skills groups to improve peerrelationships has had mixed results in effectiveness(Pfiffner, Barkley & DuPaul, 2006). Play seems an obviousmedium, as it is the natural context within which childrenlearn to socialise and make friends (Power, 2000). Whilethere is no research specifically on including childrenwith ADHD in interventions, the idea of including peersin interventions is supported in general in the inclusiveframework for children with disabilities adopted inmany countries (Turnbull, Stowe, Turnbull & Schrandt,2007), as it provides children with disabilities with theopportunity to acquire skills that would not have beenpossible if they were grouped together with like children(Hunt & McDonnell, 2007). Integrating children withdisabilities with typically developing children also isbeneficial to the typically developing children as itpromotes altruism. Therefore it makes sense, both theoreti-

cally and intuitively, to involve and support the playmatesof children with ADHD in interventions.

Considerations in including playmates in the intervention:Targeting dyadic friendships of children with ADHDmay provide a more realistic means for improving peerrelationships, than attempting to improve peer relation-ships using social skills training in a group (Hoza, Mrug,Pelham, Greiner & Gnagy, 2003). Ultimately, the interven-tion should be geared towards forming friendships asthese potentially counteract the adverse outcomesassociated with peer rejection (Hoza et al.). The friend-ship between ‘Evan’ and ‘Troy’ clearly demonstrates thepotential protective value of a close friendship for childrenwith ADHD.

Peer- and sibling-mediated interventions have shownto be effective in enhancing the social play of childrenwith autism. Even though difficulties in play are differentfor children with ADHD compared with children withautism, some of the principles used in social playinterventions for children with autism can be considered.Using peers and siblings as change agents is an exampleof such interventions (Strain, 2002). Peer-mediatedinterventions assume that training typically developingpeers to initiate, prompt and reinforce social interactionswill result in greater improvements in social playbehaviours than simply having children with autism inclose physical proximity to typically developing peers. Astandard training protocol is used to teach the typicallydeveloping peers to deliver specific social offers (e.g.‘Do you want to play?’), assuring uniformity and qualityinstruction (Strain). Peers role-play with adults until theyhave learned the strategies; they are then prompted tointeract with the target children around designated playmaterials and activities. External reinforcements aresystematically and carefully faded as the peer acquiresthe necessary skills (Strain).

The Integrated Play Group (IPG) model is anothereffective intervention using playmates and siblings. Bypromoting ‘common focus’ on an activity, the IPG modelhas been found to double the amount of interaction withpeers, increase functional object use and decrease manip-ulative, repetitive and isolated play (Wolfberg, 2003). TheIPG model emphasises arranging the environment tofoster mutually enjoyable social interaction, play andimaginative experiences (Wolfberg). The target child isencouraged to engage in and maintain interactions withpeers who, in turn, learn to use a variety of skills (e.g.getting a friend’s attention, sharing, requesting, organisingplay and giving compliments).

Regardless of the approach, interventions for childrenwith ADHD should be geared towards support ofplaymates to help children with ADHD shift theirsocial behaviour away from the tendency towardsdomination and disruption. This can be achieved byoptimising the playmates’ strengths (e.g. perseverance,adaptability and being process focussed) (Cordier et al.,2009).

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While critical to promoting the social development ofchildren with ADHD, including playmates in interventionmay be difficult. Our work as well as previous researchhas shown that children with ADHD tend to affiliatewith other children who experience peer problems(Cordier et al., 2009; Marshal & Molina, 2003) andsimilarly display negative and antisocial behaviour(Mrug, Hoza & Gerdes, 2001) and their siblings (whoare common playmates) are also at risk of emotional andbehavioural difficulties (Mash & Johnston, 1983). Clearly,further research on the playmates of children with ADHDis needed.

Finally, in promoting friendships for children withADHD, therapists need to consider the difficulties thechildren experience in responding to (and presumablyreading) cues during social play. When they are playing,all creatures (not only humans), provide clear cues abouthow they want to be treated (Bateson, 1971, 1972). Forinstance, to initiate social play, dogs adopt a characteristicposture called the ‘play bow’ — forelegs flexed; rear legsextended; rump in the air with tail wagging — that theyuse as both invitation and commentary. The dog performsa play bow at the beginning of a play bout, crouchingback into it if a nip is accidentally too hard and the otherdog wants assurance: ‘Don’t worry! Still playing!’ Bateson(1972, 2000) said it cleverly, ‘The playful nip denotes thebite, but it does not denote what would be denoted bythe bite (p. 180)’. Children with ADHD need to developtheir own social play language — expressive as well asreceptive — using verbal and non-verbal cues that denoteplay and promote the flow of the play transaction.

Conclusions

The importance of play in the social development ofchildren is undisputed. Findings from our study andprevious studies underscore that the play of childrenwith ADHD is severely affected, which potentially couldlead to adverse outcomes in adulthood. Literature onplay and ADHD allowed us to propose a model of theinteractive process between the elements of play and theprimary characteristics of ADHD. We then tested andsubsequently revised the model, which we have putforward in this paper. The revised model of the interactiveprocess between the elements of play and the characteristicsof ADHD can be used as a guide to plan interventionsfor children with ADHD, using play as a medium forintervention. Such interventions should capture thechildren’s motivations, counteract the effects of lack ofinterpersonal empathy, and include a playmate whomust be supported actively.

ReferencesAeri, P. & Verma, S. K. (2004). Child’s socialization through

play among 2–4 year old children. Anthropologist, 6, 279–281.

Alessandri, S. M. (1992). Attention, play, and social-behaviorin ADHD preschoolers. Journal of Abnormal Child Psychology,20, 289–302.

American Psychiatric Association (2000). Diagnostic andstatistical manual of mental disorders (4th, text revised, eds).Washington, DC: Author.

Bandura, A. (1989). Social cognitive theory. In: R. Vasta (Ed.)Annals of child development: Vol. 6. Six theories of child devel-opment: Revised formulations and current issues (pp. 1–60)London: JAI.

Barkley, R. A. (1995). Workshop manual: Attention deficithyperactivity disorder in children and adolescents. Worcester,MA: Author.

Barkley, R. A. (1997). Behavioral inhibition, sustainedattention, and executive functions: Constructing a unifyingtheory of ADHD. Psychological Bulletin, 121, 65–94.

Barkley, R. A. (2006). A theory of ADHD. In: R. A. Barkley(Ed.) Attention deficit hyperactivity disorder: A handbook fordiagnosis and treatment, (3rd edn, pp. 297–336). New York:Guilford.

Barkley, R. A., DuPaul, G. J. & McMurray, M. B. (1990). Acomprehensive evaluation of attention deficit disorderwith and without hyperactivity. Journal of Consulting andClinical Psychology, 58, 775–789.

Bateson, G. (1971). The message, ‘this is play’. In: R. E.Herron & B. Sutton-Smith (Eds.) Child’s play (pp. 261–269).New York: Wiley & Sons.

Bateson, G. (1972). Toward a theory of play and fantasy. In:G. Bateson (Ed.) Steps to an ecology of the mind (pp. 14–20).New York: Bantam.

Bateson, G. (2000). Steps to an ecology of mind. Chicago, IL:Chicago University, (Original work published in 1972).

Bundy, A. (2004). Test of playfulness (Top), Version 4.0.Sydney, NSW: University of Sydney.

Cordier, R., Bundy, A., Hocking, C. & Einfeld, S.(2009). Playing with a Child with ADHD: A Focus on thePlaymates. Scandinavian Journal of Occupational Therapy,doi: 10.1080/11038120903156619.

Cordier, R., Bundy, A., Hocking, C. & Einfeld, S.(forthcoming). Empathy in the play of children withADHD. Occupational Therapy Journal of Research.

Csikszentmihalyi, M. (1990). Flow: The psychology of optimalexperience. New York: Harper Perennial.

Dennis, D. (1996). Attribution theory and the glass ceiling:Career development among federal employees. PublicAdministration and Management: An Interactive Journal.http://www.hbg.psu.edu/faculty/jxr11/glass1sp.html.

Diamond, A. (2005). Attention deficit disorder (attentiondeficit hyperactivity disorder without hyperactivity): Aneurobiologically and behaviorally distinct disorder fromattention deficit hyperactivity disorder (with hyperactivity).Development and Psychopathology, 17, 807–825.

Dinklage, D. & Barkley, R. A. (1992). Disorders of attentionin children. In: S. J. Segalowitz & I. Rapin (Eds.), Handbookof neuropsychology, Volume 7: Child neuropsychology (pp. 279–307). Amsterdam: Elsevier.

Dodge, K. (1983). Behavioral antecedents of peer socialstatus. Child Development, 54, 1386–1399.

Fadely, J. L. & Hosler, V. N. (1992). Attention deficit disorder inchildren and adolescents. Springfield, IL: Charles C. Thomas.

340 R. CORDIER ET AL.

© 2009 The AuthorsJournal compilation © 2009 Australian Association of Occupational Therapists

Hoffman, M. L. (2001). Empathy and moral development:Implications for Caring and Justice. Cambridge, UK: Cam-bridge University.

Hoza, B., Mrug, S., Pelham, W. E., Greiner, A. R. & Gnagy,E. M. (2003). A friendship intervention for children withattention deficit hyperactivity disorder: Preliminaryfindings. Journal of Attention Disorders, 6, 87–98.

Hunt, P. & McDonnell, J. (2007). Inclusive education. In: S.Odom, R. Horner, M. Snell & J. Blacher (Eds.), Handbook ofdevelopmental disabilities. (pp. 269–291). New York: Guilford.

Leipold, E. E. & Bundy, A. (2000). Playfulness in childrenwith attention deficit hyperactivity disorder. OccupationalTherapy Journal of Research, 20(1), 61–82.

Malaguzzi, L. (1998). History, ideas and basic philosophy.In: C. Edwards, L. Gandini & G. Forman (Eds.), Thehundred languages of children: The Reggio Emilia approachadvanced reflections (2nd ed., pp. 49–98). London: Ablex.

Marshal, M. P. & Molina, B. S. G. (2003). Childhood ADHDand adolescent substance use: An examination of deviantpeer group affiliation as a risk factor. Psychology of Addic-tive Behaviors, 17, 293–302.

Mash, E. J. & Johnston, C. (1983). Sibling interactions ofhyperactive and normal children and their relationshipto reports of maternal stress and self-esteem. Journal ofClinical Child Psychology, 12, 91–99.

Melnick, S. & Hinshaw, S. (1996). What they want and whatthey get: The social goals of boys with ADHD andcomparison boys. Journal of Abnormal Child Psychology, 24,169–185.

Moyles, J. (1989). Just playing: The role and status of play inearly childhood education. London: Open University.

Mrug, S., Hoza, B. & Gerdes, A. C. (2001). Children withattention deficit hyperactivity disorder: Peer relation-ships and peer-oriented interventions. In: D. W. Nangle &C. A. Erdley (Eds.), The role of friendship in psychologicaladjustment (pp. 51–77). San Francisco, CA: Jossey-Bass.

Neumann, E. A. (1971). The elements of play. New York: MSSInformation.

Parham, L. D. (2008). Play and occupational therapy. In: L.D. Parham & L. S. Fazio (Eds.), Play in occupational therapyfor children, (2nd edn, pp. 3–42). St. Louis, MO: Mosby.

Pfiffner, L. J., Barkley, R. A. & DuPaul, G. J. (2006). Treat-ment of ADHD in school settings. In: R. A. Barkley (Ed.),Attention deficit hyperactivity disorder: A handbook for diagnosisand treatment (3rd ed., pp. 547–598). New York: Guilford.

Power, T. G. (2000). Play and exploration in children and animals.Hillsdale, NJ: Erlbaum.

Schachar, R. (1991). Childhood hyperactivity. Journal of ChildPsychology and Psychiatry, 32(1), 155–191.

Skard, G. & Bundy, A. (2008). Test of playfulness. In: L. D.Parham & L. S. Fazio (Eds.), Play in occupational therapy forchildren, (2nd ed., pp. 71–93). St. Louis, MO: Mosby.

Stambak, M. & Sinclair, H. (1993). Pretend play among 3-yearolds. Hillsdale, NJ: Lawrence Erlbaum.

Strain, P. S. (2002). Nurturing social skills in the inclusiveclassroom (workbook). Tualatin, OR: Teacher’s Toolbox, orhttp://www.ttoolbox.com/teacher_training.htm.

Strain, P. S. & Danko, C. D. (1995). Caregivers’ encouragementof positive interaction between preschoolers with autismand their siblings. Journal of Emotional and BehavioralDisorders, 3, 2–13.

Sutton-Smith, B. (1997). The ambiguity of play. Cambridge,MA: Harvard University.

Turnbull, H. R., Stowe, M. J. & Schrandt, M. (2007). Publicpolicy and developmental disabilities: A 35-year retrospectiveand a five-year prospective based on the core conceptsof disability policy. In: S. Odom, R. Horner, M. Snell &J. Blacher (Eds.), Handbook of developmental disabilities.(pp. 15–34). New York: Guilford.

Wolfberg, P. J. (2003). Peer play and the autism spectrum: Theart of guiding children’s socialization and imagination.Shawnee Mission, KS: Autism Asperger Publishing.

Wood, K. (1995). Attention deficit hyperactivity disorder: Aguide for professionals. Melbourne, Vic.: La Trobe University.

Zimbardo, P. G. (1985). Psychology and life. Glenview, IL:Scott Foreman.