Fateme Nourkojouri; narges pourtaleb; Elnaz MusaNejad
Abstract
The primary objective of this study was to establish the efficacy of play therapy grounded in executive functions in addressing the attention deficit and impulsivity observed in students diagnosed with attention deficit hyperactivity disorder. This experiment was conducted in a quasi-experimental manner, ...
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The primary objective of this study was to establish the efficacy of play therapy grounded in executive functions in addressing the attention deficit and impulsivity observed in students diagnosed with attention deficit hyperactivity disorder. This experiment was conducted in a quasi-experimental manner, involving a pretest-posttest with a control group. The statistical population in this study encompassed all male students with Attention Deficit/Hyperactivity Disorder (ADHD), aged between 8 to 10 years old within Tabriz City, during the academic year 2022-2023. The statistical sample consisted of 30 students diagnosed with Attention Deficit/Hyperactivity Disorder, identified by consultation with the school counselor and assessment using the CSI-4 scale. A convenience sampling method was employed to select the participants, and they were subsequently divided randomly into two groups: experimental and control. Both groups were evaluated using the software versions of the Stroop and Go-No go tests, in phases of pre-test and post-test. The experimental group engaged in group play therapy grounded in executive functions for a total of 10 sessions, each session lasting 60 minutes, held once a week. The data obtained from the study was subjected to multivariate analysis of covariance for further analysis. The significance level was set at 0.05 in all tests. The results indicated that a significant difference was observed between the experimental and control groups in the attention deficit variable, while no significant difference was found in the impulsivity variable. Based on the outcomes generated through this research, play therapy grounded in executive functions, coupled with targeted interventions focusing on bolstering executive functions, can enhance children with Attention Deficit/Hyperactivity Disorder's attention deficit issues significantly.Keywords: Play Therapy based on Executive Functions, Impulsivity, Executive Functions, Attention Deficit, Attention Deficit Hyperactivity Disorder. Extended Abstract IntroductionAttention Deficit Hyperactivity Disorder (ADHD) is classified as a neurodevelopmental disorder under the section for Neurodevelopmental Disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Neurodevelopmental disorders are disorders that manifest during the developmental stages—the period of time that begins at conception at birth and extends till the child reaches adulthood—and are primarily rooted in neurological factors. These disorders are identified before a child begins attending school and are marked by developmental impairments that disrupt personal, social, academic, or occupational functioning (Tobin & House, 2020). Children diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) encounter difficulties in concentrating on tasks and following instructions. They often find it challenging to maintain focus on tasks, especially those they deem less engaging (Schroeder & Gordon, 2021). Additionally, they may experience problems with tasks that require executive functions, including planning, organization, time management, and self-regulation, as well as tasks involving working memory, sustained attention, or switching between various tasks.Attention is the critical and foundational function of the brain, involving the capacity to pick and process important information, while sustaining and manipulating it throughout the entire processing phase. Attention deficit refers to the inability to maintain focus and consistently complete tasks, particularly those deemed boring, monotonous, or extensive (Schroeder & Gordon, 2021). Barkley asserts that the lack of attention exhibited by these children can be attributed to issues with the interaction between inhibition and executive functions. Inhibition, also known as impulse control, is a key element of executive functions that regulates behavior through internally perceived information, including mental imaging, internal speech, and self-motivation (Yavari et al., 2020).If children with Attention Deficit/Hyperactivity Disorder (ADHD) are not diagnosed and treated promptly, the consequences can be severe, resulting in teenagers and adults experiencing job failures, displays of aggression, challenges in interpersonal relationships, and other psychological disorders such as substance abuse, alcohol abuse, depression, and anxiety (Biderman & Spenser, 2005; Yahyavi Zanjani et al., 2021). One of the suggested therapeutic approaches for children with Attention Deficit/Hyperactivity Disorder (ADHD) is play therapy (Samadi, 2019). Play therapy provides a valuable opportunity to create an environment that allows children to acquire appropriate experiences with the assistance of a therapist, thereby reinforcing pre-social, behavioral, and emotional skills. Within the context of the play environment and under the guidance of experts, children, who may struggle to learn these skills in other settings, have an opportunity to easily grasp them through play (Shahi et al., 2020). Literature ReviewResearch findings suggest that games focused on attention concentration can help improve attention span and reduce impulsivity in students diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD) (Yahyavi Zanjani et al., 2020). Additionally, a separate study explored the effects of play therapy grounded in executive functions on enhancing the executive functions of children with ADHD. Research has indicated that interventions designed to enhance the executive functions of children with ADHD can lead to improved selective attention, inhibition, and cognitive flexibility (Shahi et al., 2020). Moreover, studies on the training of executive functions in preschool children diagnosed with ADHD have shown reductions in symptoms of inattention and impulsivity (Shuai et al., 2021). In addition, research has discovered that sports interventions have a positive impact on the executive functions of both children and adolescents with ADHD (Liang et al., 2021). MethodologyThis study utilized a semi-experimental design with a pre-test-post-test framework and a control group. The statistical population in this research included all male students aged 8 to 10 years old who had Attention Deficit/Hyperactivity Disorder (ADHD) within Tabriz during Academic Year 1402-1401. The study's sample consisted of 30 students diagnosed with Attention Deficit/Hyperactivity Disorder selected through convenience sampling, with permission from the Tabriz City Education Authorities and in consultation with the primary schools of boys. The inclusion criteria for sample selection were as follows: a diagnosis of ADHD, male gender, age between 8 and 10 years, average IQ, a lack of current medication use, and no participation in other treatments connected to ADHD.The exclusion criteria for participating in this study encompassed the absence from more than two sessions and the presence of any comorbid disorders, including anxiety, depression, or other mental health conditions. The Raven's Intelligence Quotient (IQ) test was administered to each participant to determine their level of intelligence. Both groups underwent two rounds of assessment: a pre-test and a post-test. The software versions of the word-color Stroop test and the forward digit span test were utilized for evaluation. Following the pre-test, the experimental group embarked on 10 sessions of play therapy aimed at enhancing executive functions, spaced over a period of two and half months (one session a week, with each session lasting 60 minutes). The control group did not receive any intervention. ResultThe statistical evaluation of the data was executed in two steps: using descriptive statistics (mean and standard deviation) and inferential statistics. Table 1 presents the descriptive data regarding the variables of attention deficit and impulsivity, segregated by group and test.Table 1. Descriptive data of attention deficit and impulsivity variables according to experimental & Control groupsVariableComponentsGroupPre-testPost-testMSMSAttention DeficitConsonant reaction timeExperimentalControl43/4342/551/231/271/181/3122/6226/28Anomalous reaction timeExperimentalControl37/3443/221/261/291/231/3831/1542/62Consonant errorExperimentalControl1/061/460/130/481/331/060/300/28Inconsistent errorExperimentalControl3/934/401/192/041/3311/060/252/98Correct consonantExperimentalControl43/4043/361/140/6845/5343/730/320/62Incongruent correctExperimentalControl39/0630/062/402/6344/0628/530/673/71Interference scoreExperimentalControl4/334/601/582/611/4615/200/543/72Interference timeExperimentalControl20/7317/0012/9217/9142/4071/2614/1433/02Percentage rendering errorExperimentalControl34/6035/534/413/6026/3335/8013/2114/05Impulsiveness ExperimentalControl23/5317/205/883/8015/0019/864/473/96ExperimentalControl48/6652/334/934/2763/1350/264/814/66ExperimentalControl26/5931/683/484/0926/5937/863/484/02To evaluate the efficacy of play therapy on executive functions linked to attention deficit and impulsivity, multivariate analysis of covariance (ANCOVA) was implemented, complemented by one-way ANOVA to contrast the difference between the groups. Furthermore, the Kolmogorov-Smirnov test was conducted to confirm the distribution of the studied variables across the groups, which validated the normality assumption for ANCOVA analysis.The Z values calculated at the significance level (P < 0.05) were not significant. To assess the equality of error variance of the post-test variables between the experimental and control groups, Levene's test was utilized. The F value calculated for the variables was not significant, thus confirming this assumption as well. Consequently, the Pillai's trace statistic was reported as a multivariate index, with the results presented in Table 2.Table 2. Descriptive data of attention deficit and impulsivity variables according to test groupsVariableSourcesPillai's TracefdfSigEffect sizeAttention DeficitGroup0/6193/7860/0190/619Time*group0/9862/43120/0240/493Impulsivenessgroup0/1720/9840/4380/172Time*group0/3891/2080/3190/195 The findings from the multivariate analysis of covariance (ANCOVA) revealed a significant difference in the attention deficit variable between the experimental and control groups (effect size = 0.493, P < 0.001), indicating that play therapy grounded in executive functions was efficient in enhancing the attention deficits of the experimental group. Conversely, the impulsivity variable showed no significant difference between the two groups, with an effect size of 0.195 (P < 0.001). DiscussionThe main aim of this study was to explore the effectiveness of play therapy, anchored in executive functions, on attention deficits and impulsivity in individuals diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD). The results unequivocally established that play therapy centered on executive functions significantly enhances attention deficits in this particular group of students. Additionally, this study's findings are in line with the outcomes of prior research. When discussing the effectiveness of play therapy on executive functions and its influence on improving attention deficits in children with Attention Deficit/Hyperactivity Disorder (ADHD), the hyperarousal hypothesis takes on significant relevance. According to this hypothesis, the indicators of Attention Deficit/Hyperactivity Disorder (ADHD) stem from inadequate stimulation of the brain by environmental stimuli, resulting in a state of reduced arousal in affected individuals. As a result, the ability to pay selective attention is also compromised, causing affected individuals to give equal attention to both significant and irrelevant stimuli. This implies that individuals with ADHD find it challenging to distinguish essential stimuli from insignificant environmental cues, such as the sound of a closing door, and react to both with equal attention (Yadollahi & Mehrparvar, 2019).It is worth noting that this treatment did not yield significant improvements in the impulsivity of students diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD). The outcomes related to the impulsivity variable diverged from those of previous research studies. Given that impulsivity, impulse control, and response inhibition are significant issues in children diagnosed with ADHD, addressing these concerns necessitates more than mere targeted exercises. Effective management of impulsivity in children with Attention Deficit/Hyperactivity Disorder (ADHD) necessitates a comprehensive approach that involves behavioral training for both parents and teachers. It becomes apparent that undertaking these tasks independently is inadequate in reducing symptoms of impulsivity in these children, and collaboration between families and schools is crucial in the treatment process. Equipping parents with behavioral management strategies and empowering them to control environmental stimuli can facilitate the development of inhibition and self-control behaviors in these children. ConclusionBased on the research outcomes, it can be posited that play therapy, grounded in executive functions and utilizing targeted techniques and methodologies, may efficaciously assuage the symptoms of Attention Deficit/Hyperactivity Disorder (ADHD). This approach may potentially ameliorate impulsivity and augment impulse control in students diagnosed with ADHD, consequently ameliorating their interpersonal and academic relationships. Given the considerable impact that children and students hold within their families and society, it becomes imperative to address this disorder for optimal future personal, academic, and social development. Consequently, it is suggested that this therapeutic approach be introduced in both private and public psychology clinics. The findings of this study have the capability to significantly benefit not only parents, but also child psychotherapists and teachers. It can be construed as a significant stride towards augmenting the cognitive and behavioral skills of children diagnosed with ADHD, facilitating healthier psychological well-being both for the children and their families, and ultimately working towards forestalling potential future obstacles for these individuals.AcknowledgementsThe authors would like to extend their profound appreciation to the participants in this research, encompassing the managers, teachers, and parents of students in the city of Tabriz, for their invaluable collaboration in the implementation of this study.
Mahsa Zolfaghari; mohsen shakerinasab
Abstract
Abstract
Sometimes, the presence of impulsive behaviors in children with attention deficit/hyperactivity disorder increases their social problems, and the amount of interaction with their parents can increase their abilities. Based on this, the present study was conducted with the aim of determining ...
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Abstract
Sometimes, the presence of impulsive behaviors in children with attention deficit/hyperactivity disorder increases their social problems, and the amount of interaction with their parents can increase their abilities. Based on this, the present study was conducted with the aim of determining the effectiveness of parent-child joint play on reducing impulsivity and increasing the social skills of children with attention deficit/hyperactivity disorder. In this research, a semi-experimental method was used with a pre-test and post-test design with a control group, and its statistical population consisted of all children with attention deficit/hyperactivity disorder in Bojnord city and their mothers in 2022, 30 of whom were selected by purposive sampling and were randomly placed in two groups of 15 people, experimental and control. For both groups, the pre-test, including Barth's impulsivity scale (1995) and Matson's social skills scale (1983), was implemented, and the experimental group had 8 two-hour weekly sessions under the joint game. The parent and the child were placed and the control group did not receive any intervention. Both groups completed the post-test again and the results were analyzed through analysis of covariance. The findings showed that Parent-child joint play is effective in reducing impulsivity and increasing the social skills of children with attention deficit/hyperactivity disorder. The results of this research show that parent-child joint play can be used to reduce behavioral problems and increase the social skills of children with attention deficit/hyperactivity disorder.
Keywords: Parent-Child Joint Play, Impulsivity, Social Skills, Children with Attention Deficit/Hyperactivity Disorder.
Extended Abstract
Introduction
Attention deficit/hyperactivity disorder in children is one of the most common neurodevelopmental disorders that causes many problems for children. The presence of this disorder causes many problems for these children, and impulsive and thoughtless behaviors are one of the major problems. Unmeasured and sudden behaviors in children with attention deficit/hyperactivity disorder cause them to be criticized and blamed by others, their interpersonal relationships face problems, and their social skills are weakened. The problems related to children with attention deficit/hyperactivity disorder have caused various educational and therapeutic theories and approaches to be used all over the world, and the use of game techniques has been more welcomed by children and therapists due to their diversity and high attractiveness. Some therapists have emphasized the role of parents' therapy in the form of games and stated that parents' participation in play therapy can play a facilitating role. In the joint game between parent and child, it is emphasized to create a strong relationship between parent and child regarding the game, and this advantage is used to improve the child's problematic behavior, which is planned by the therapist and the parent as a facilitator, creates a greater impact.
Research Question
Is parent-child joint play effective in reducing impulsivity and increasing the social skills of children with attention deficit/hyperactivity disorder?
Literature Review
In a research, Parlad et al. (2020) showed that the use of mutual play between parents and children is effective in improving children's social functions, and Cohen et al. (2022) also showed that joint play therapy between parents and children can be effective on children's social adaptation due to better interaction and increase their social ability. The research of Branovich and Han (2019) also shows that the use of joint play between parents and children can be effective on children's psychological abilities and provide the possibility of learning social skills and correcting negative behaviors. Also, Dietman et al. (2016) in their research mentioned the role of parent-child communication through play in reducing children's disobedience and stubbornness and stated that this kind of play therapy method provides the possibility of correcting negative behaviors due to the creation of better interactive conditions.
Methodology
In terms of the method of data collection, the present study was a semi-experimental type with a pretest-posttest design with a control group, and its statistical population was all children aged 4 to 7 years with attention deficit/hyperactivity disorder (predominant hyperactivity) and their mothers, who in 2022, were admitted to one of the private counseling centers in Bojnord city. In addition to obtaining a score higher than 34 in the Connors Attention Deficit/Hyperactivity Disorder diagnosis questionnaire (parent version), these children were also subjected to a clinical interview by the center's psychiatrist based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and a definitive diagnosis of Attention Deficit Disorder / had received hyper-activity. The research sample included 30 of these children along with their mothers, who were selected by purposeful sampling and randomly replaced in two experimental and control groups. Both groups completed the scale of impulsive behaviors and social skills about their child as a pre-test before any intervention in the same conditions. Then, for the experimental group, a joint parent-child game program was implemented; while the group did not receive a training certificate. Finally, after the end of the training sessions, the scale of impulsive behaviors and social skills was implemented again as a post-test for both groups. The data collection tools were: Children with Attention Deficit/Hyperactivity Disorder (CPRS), Impulsive Behavior Scale (BIS), and Social Skills Questionnaire (MESSY). Also, in this study, in the experimental group, the joint play program of parent and child was based on the model. Landreth (2006) was implemented as a group in 8 two-hour sessions for mothers and children of the experimental group.
Results
The mean and standard deviation of the research variable and their subscales according to the test and control groups in the pre-test and post-test situations are shown in Table 1.
Table 1. Mean and standard deviation of the research variable by test and control groups
posttest
Pretest
variables
group
SD
M
SD
M
2.28
59.75
2.24
74.06
Total impulsivity
experimental group
1.28
20.43
1.13
26/87
Lack of planning
1.49
24.22
1.45
28.60
Movement impulsivity
1.44
15.10
1.84
19.13
Cognitive impulsivity
3.64
132.56
3.88
110.45
Total Social skills
control group
2.06
29.22
2.12
26.12
Appropriate social skills
2.11
30.67
2.09
24.02
antisocial behaviors
2.04
24.30
2.19
18.11
Aggression and impulsiveness
2.11
20.17
2.18
18.26
Supremacy
2.09
28.20
2.11
24.14
Relationship with peers
The findings presented in the table show that in the experimental group, impulsivity and its components decreased in the post-test situation, while there was no significant change in scores in the control group. It can also be seen that social skills and their components increased in the post-test situation, while there was no significant change in scores in the test group. Before conducting the covariance analysis, the assumptions of using parametric statistics such as the Kolmogorov-Smirnov test, the Levin test, and the homogeneity of the regression slope were examined, and the results of the Kolmogorov-Smirnov test showed the level of significance in the test for each of the variables of impulsivity and social skills in the situation. The pre-test and post-test are more than 0.05 and as a result, it can be said that the normality of the distribution of the variables has been confirmed. Also, the assumption of homogeneity of variances was checked with Levine's test, and the results showed that the coefficient of the significance level of the test to check the homogeneity of variances for each of the research variables was more than 0.05, and as a result, it can be said that the variance of the groups has homogeneity. Also, the results of the regression slope investigation showed that the obtained value of both interaction effects is not significant at the 0.05 level, and the assumption of homogeneity of the regression slopes has been met, therefore, there is no problem with the presuppositions under investigation.
The results of covariance analysis to determine the effectiveness of parent-child joint play on reducing impulsivity and increasing social skills of children with attention deficit/hyperactivity disorder are according to Table 2.
Table 2. Multivariate covariance analysis test
Test
value
F
df
df error
sign
eta
Pillai effect
0.88
18.67
2
26
0.001
0.92
Wilkes Lambda
0.84
6.87
2
26
0.001
0.92
Hetling effect
4.14
77.18
2
26
0.001
0.92
The largest root on
30.11
7
2
26
0.001
0.92
The results listed in Table 2 show that there is a significant difference between the control and experimental groups in the research variables. In order to investigate this change, the univariate covariance test was used, the results of which are presented in Table 3.
Table 3. Univariate covariance analysis test on impulsivity and social skills scores
Variable
Source of changes
SS
df
MS
F
sign
eta
impulsivity
Pre-test impulsivity
781.75
1
781.75
18.44
0.001
0.34
Group membership
5291.02
1
5291.02
124/81
0.001
0078
social skills
Pre-test impulsivity
793.84
1
793.84
26.97
0.000
0.43
Group membership
4714.23
1
4714.23
45.116
0.000
0.82
As can be seen in the above table, with the pre-test evidence, a significant difference can be seen between the test group and the evidence in the impulsivity variable. In this way, the average post-test scores of the experimental group are significantly lower than the control group; and the effect or difference is equal to 0.78, which means that 78% of the individual differences in impulsivity scores were related to the effect of parent-child joint play. It can also be seen that, with pre-test control, there is a significant difference between the experimental and control groups in the variable of social skills. In this way, the average post-test scores of the experimental group are significantly higher than the control group and the effect or difference is equal to 0.82, which means that 82% of individual differences in social skills scores were related to the effect of parent-child joint play.
Discussion
It seems that the emphasis on the relationship between the parent and the child in regard to playing therapy has been able to provide a friendly and tension-free atmosphere for the child, which has led to listening more to the parent and imitating his positive behaviors, and in this way, the child has been able to manage impulsive behaviors and reflect on giving answers and develop his social skills. Since the focus of the parent-child joint game approach is on improving the parent-child relationship, the development of the intervention program by the therapist, which was carried out with the aim of correcting the child's problems and increasing his capabilities, has strengthened the child's inner self and his potential abilities to manifest positive behaviors and has helped the mother to better understand the child's emotional world and to gain an attitude be realistic and patient towards your child. This increase in insight and awareness has created a non-judgmental, accepting, and mutual understanding atmosphere and has influenced the behavior of children with attention deficit/hyperactivity disorder and has reduced their psychological problems, and increased their social skills.
Conclusion
The result of this research shows that parent-child joint play can be used to reduce behavioral problems and increase the social skills of children with attention deficit/hyperactivity disorder.
Acknowledgments
We are grateful to all colleagues and friends who helped us in the implementation of this research. Also, we are especially grateful to all the children and mothers who participated in this research.