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

Introduction

Attention 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 Review

Research 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).

Methodology

This 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.

Result

The 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 groups




Variable


Components


Group


Pre-test


Post-test




M


S


M


S






Attention Deficit


Consonant reaction time


Experimental
Control


43/43
42/55


1/23
1/27


1/18
1/31


22/62
26/28




Anomalous reaction time


Experimental
Control


37/34
43/22


1/26
1/29


1/23
1/38


31/15
42/62




Consonant error


Experimental
Control


1/06
1/46


0/13
0/48


1/33
1/06


0/30
0/28




Inconsistent error


Experimental
Control


3/93
4/40


1/19
2/04


1/33
11/06


0/25
2/98




Correct consonant


Experimental
Control


43/40
43/36


1/14
0/68


45/53
43/73


0/32
0/62




Incongruent correct


Experimental
Control


39/06
30/06


2/40
2/63


44/06
28/53


0/67
3/71




Interference score


Experimental
Control


4/33
4/60


1/58
2/61


1/46
15/20


0/54
3/72




Interference time


Experimental
Control


20/73
17/00


12/92
17/91


42/40
71/26


14/14
33/02




Percentage rendering error


Experimental
Control


34/60
35/53


4/41
3/60


26/33
35/80


13/21
14/05




Impulsiveness


 


Experimental
Control


23/53
17/20


5/88
3/80


15/00
19/86


4/47
3/96




Experimental
Control


48/66
52/33


4/93
4/27


63/13
50/26


4/81
4/66




Experimental
Control


26/59
31/68


3/48
4/09


26/59
37/86


3/48
4/02




To 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 groups




Variable


Sources


Pillai's Trace


f


df


Sig


Effect size






Attention Deficit


Group


0/619


3/78


6


0/019


0/619




Time*group


0/986


2/43


12


0/024


0/493




Impulsiveness


group


0/172


0/98


4


0/438


0/172




Time*group


0/389


1/20


8


0/319


0/195




 
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).

Discussion

The 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.

Conclusion

Based 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.
Acknowledgements
The 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.