Journal of Occupational Therapy, Schools, & Early

Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: http://www.tandfonline.com/loi/wjot20

A systematic review of play-based interventions

for students with ADHD: implications for school-
based occupational therapists

Heidi R Cornell, Tiffany Ting Lin & Jeffrey Alvin Anderson

To cite this article: Heidi R Cornell, Tiffany Ting Lin & Jeffrey Alvin Anderson (2018): A systematic
review of play-based interventions for students with ADHD: implications for school-based
occupational therapists, Journal of Occupational Therapy, Schools, & Early Intervention, DOI:
10.1080/19411243.2018.1432446

To link to this article: https://doi.org/10.1080/19411243.2018.1432446

Published online: 09 Feb 2018.

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JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
https://doi.org/10.1080/19411243.2018.1432446

A systematic review of play-based interventions for students

with ADHD: implications for school-based occupational
therapists
Heidi R Cornella, Tiffany Ting Linb, and Jeffrey Alvin Andersonc
a
Department of Curriculum and Instruction, College of Education, Wichita State University, Kansas;
b
Department of Occupational Therapy, College of Applied Health Science, University of Illinois at Chicago,
Illinois; cDepartment of Curriculum and Instruction, School of Education, Indiana University Bloomington,
Indiana

ABSTRACT ARTICLE HISTORY

The results are presented from a systematic review of the literature Received 29 September 2017
that examined findings of published studies about play-based inter- Accepted 22 January 2018
ventions for children and youth with ADHD. Guided by the research KEYWORDS
question, “What is the current status of evidence for using play-based Occupational therapy;
interventions to improve outcomes for students with ADHD?,” this attention deficit disorder
study evaluated methodological quality using the quality indicators with hyperactivity; play
developed by the Council for Exceptional Children (CEC). Although
findings suggest that play-based interventions for students with
ADHD cannot be considered an evidence-based practice, it does
appear to be a promising practice. Future research and implications
for school-based occupational therapists are shared.

Prevalence estimates indicate that approximately 11% of school-aged children are identi-
fied with attention deficit hyperactivity disorder (ADHD) (Abdollahian, Mokhber,
Balaghi, & Moharrari, 2013), making it one of the most commonly occurring externalizing
disorders in childhood (Centers for Diseases Control and Prevention data & statistics,
2016). Children and adolescents diagnosed with ADHD tend to display developmentally
inappropriate levels of inattention and/or hyperactivity–impulsivity that are associated
with clinically significant impairment in academic and/or social functioning (American
Psychiatric Association, 2013; Barkley, 2015). Consistent with these defining characteris-
tics, it is common for individuals with ADHD to experience challenges when interacting
socially with others (Greene et al., 1999; Hoza, 2007; Mikami & Hinshaw, 2003).
Researchers have suggested that these social interaction problems contribute to difficulties
in maintaining positive relationships with parents, teachers, and peers (Mrug et al., 2012;
Peham, Foster, & Robb, 2007), which can greatly impact school functioning (Barkley,
Fischer, Smallish, & Fletcher, 2006; Frazier, Youngstrom, Glutting, & Watkins, 2007; Kent
et al., 2011). For example, students with ADHD are typically more socially intrusive
(Frankel & Feinberg, 2002), creating negative initial peer impressions (Erhardt &
Hinshaw, 1994). Negative peer impressions can in turn lead to fewer friendships
(Gresham, 1998) and social rejection is often a consequence (Hodgens, Cole, &
Boldizar, 2000). In fact, when compared to students without ADHD, both peers without

CONTACT Heidi R Cornell Heidi.cornell@wichita.edu Curriculum and Instruction, College of Education, Wichita
State University, 1845 Fairmount St., Wichita, Kansas 67260.
© 2018 Grace Scientific Publishing, LLC
2 H. R. CORNELL ET AL.

disabilities and teachers typically rate students with ADHD as being less socially compe-
tent (Ronk, Hund, & Landau, 2011). Consequently, students with ADHD may experience
fewer social opportunities which are necessary for learning appropriate social skills that
are central to positive school functioning and long-term development (Mikami, 2010;
Tseng, Kawabata, Gau, & Crick, 2014; Waschbusch, Craig, Pelham, & King, 2007). Thus, it
is not surprising that social problems among children with ADHD are of concern for
school professionals, due to the heightened risks for school failure, disciplinary problems
(Barkley et al., 2006; Frazier et al., 2007; Kent et al., 2011), depression, conduct disorders
and substance abuse (Greene et al., 1999; Klein et al., 2012), as well as long-term
problematic and non-productive outcomes (Barkley & Fischer, 2011; Humphreys, Eng,
& Lee, 2013; Mikami & Hinshaw, 2003; Owens & Hinshaw, 2016).

Interventions to improve school functioning

The most commonly used intervention for students with ADHD continues to be the use of
medication (Pelham & Fabiano, 2008; Slattery, Crosland, & Iovannone, 2015). This inter-
vention approach is appealing to both parents and school professionals because the use of
stimulant medication has been consistently associated with improvements in attention,
short-term memory, performance on quizzes, homework completion, and note-taking
(Bedard, Jain, Johnson, & Tannock, 2007; Douglas, 1999; Evans et al., 2001; Pelham et al.,
1993; Scheffler et al., 2009). However, to maximize opportunities for success, students with
ADHD often require additional interventions, as well. Several behavioral interventions have
also shown to help increase appropriate behaviors and reduce problematic behaviors for this
population of students (DuPaul, Gormley, & Laracy, 2014; Radley & Dart, 2016). For
example, token reinforcement is one of the more widely used behavioral interventions in
school settings. Researchers have demonstrated that this kind of intervention is associated
with many positive improvements in children with ADHD, such as staying on task during
instruction time (DuPaul, Weyandt, & Janusis, 2011). Another common school-based inter-
vention for increasing time on task for students with ADHD is to modify the length of tasks
and then provide short breaks between them (DuPaul et al., 2011). Likewise, daily report
cards, which report on specific target behaviors a student is required to exhibit and then
offers rewards (e.g., points) earned, have been shown to improve behavior and increase
home–school communication and parental involvement (DuPaul et al., 2011). While these
interventions have been found to improve some aspects of school functioning, evidence also
indicates that students with ADHD continue to struggle with development and use of
prosocial skills (Wilkes-Gillan, Bundy, Cordier, & Lincoln, 2014), suggesting that additional
intervention strategies may be needed to increase social competence. Given that children
build relationships and develop social skills, emotional maturity, and self-confidence natu-
rally through play (AOTA, 2016; Cordier, Bundy, Hocking, & Einfeld, 2009), play-based
interventions may provide an additional intervention strategy that can be used to improve
the social competence of students with ADHD.

Play-based interventions
Broadly, play is now understood as an important component in the social and mental
development of children (Stone, 2017; Vygotsky, 2016). The American Occupational
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 3

Therapy Association (2014) defines play as “any spontaneous or organized activity that
provides enjoyment, entertainment, amusement, or diversion”. Play exploration and play
participation are listed as crucial by the Occupational Therapy Practice Framework
(AOTA, 2014). Indeed, play-based interventions have been found to help children bridge
the gap between concrete and abstract expression (Landreth, 2012), and many early
interventions incorporate play skills to enhance children’s social, emotional, and beha-
vioral development (NAEYC, 2009). The U.S Department of Education (2012) defines
play-based interventions as “practices designed to improve socio-emotional, physical,
language, and cognitive development through guided interactive play,” where “during
play sessions, an interventionist uses strategies including modelling, verbal redirection,
reinforcement, and indirect instruction to sustain and encourage child play activities” (pg.
1). Table 1 provides a definition for each of these instructional strategies (i.e., modeling,
verbal redirection, reinforcement, and indirect instruction), which are commonly used in
the delivery of play-based interventions. Moreover, play-based interventions are recog-
nized as a useful method for developing social competence in students (McAloney &
Stagnitti, 2009), including students with ADHD.

Play-based occupational therapy interventions

Evidence for play-based occupational therapy interventions is limited but growing. In the
field of occupational therapy (OT), several studies have demonstrated the potential
effectiveness of using play-based OT interventions. For example, Gokhale, Solanki, and
Agarwal (2014) found play-based OT to be effective at improving play behavior of
children with Down Syndrome. Other researchers have found that some play-based OT
interventions help children cope with stress during hospitalization periods (Potasz, Varela,
Carvalho, Prado, & Prado, 2013), as well as develop psycho-social skills during adoles-
cence (Jahagirdar & Joshi, 2011). Specific to children and youth with ADHD, Nielsen,
Kelsch, and Miller (2017) conducted a comprehensive review of the literature that broadly
examined evidence for occupational therapy interventions for children with ADHD and
found a few studies focused on play-based interventions. While these interventions yielded

Table 1. Instructional strategies commonly used when delivering play-based interventions.

Instructional strategy Definition
Modeling ● To engage student(s) in imitation of behaviors to encourage learning (Bandura, 1986; 1977).

Verbal redirection ● To verbally distract student(s) attention away from an undesirable behavior or activity, while
verbally encouraging student(s) to focus on a preferred task in order to modify behavior and
increase ability to learn (Elliott, 2002; Long, 2009; Mckillip, n.d.).

Reinforcement ● To apply a stimulus in order to increase the likelihood that a response will occur (e.g., praise)
(Skinner, 1938).

Indirect instruction ● Teacher guidance that is student-centered, allowing students to continually construct
knowledge through interacting with people and the environment (Kamii, 1993; Piaget,
1970). Opposite of direct instruction which is teacher-directed and seeks to impart knowl-
edge as an expert to a less informed person (Krogh, 1994).
4 H. R. CORNELL ET AL.

good results, the authors also called for additional research. They further cautioned that
their review could have limited applicability to the OT field by possibly excluding inter-
ventions that fell within the domain of occupational therapy, but were conducted by other
professionals. As such, it is possible that no comprehensive reviews of play-based inter-
ventions for students with ADHD are currently available to guide the OT field. Thus, the
first purpose of this study was to reimage the work of Nielsen et al. (2017), to identify,
examine, and evaluate all peer-review articles that have reported research in which play-
based interventions were used to improve outcomes for individuals with ADHD. Our
systematic literature review was guided by our primary research question, “What is the
current status of evidence for using play-based interventions to improve outcomes for
students with ADHD?” Although findings are likely to be broadly beneficial, they are
specifically discussed in light of possible implications for school-based occupational
therapists.

Method
The methods used in this systematic literature review followed steps outlined by Khan,
Kunz, Kleijnen, and Antes (2003): 1) frame the question for review, 2) identify relevant
work, 3) assess the quality of studies, and 4) summarize the evidence. In addition, our
methods also adopted approaches from other published systematic reviews that have
similarly examined the status of a particular evidence base of an intervention on a
particular population of students identified as having a disability (see e.g., Ogle & Alant,
2014; Wood, Oakes, Fettig, & Lane, 2015). The specific steps used to conduct this study
are described further in the following sections.

Search procedure
First, a systematic search of psychology and educational electronic databases, including
EBSCO-Eric, EBSCO-Academic Search, JSTOR, PsycINFO, and Web of Science, was
conducted by examining titles and abstracts of the published papers. Search terms
included “play-based intervention” and “ADHD”, “play-based intervention” and “atten-
tion deficit hyperactivity disorder”, “play therapy” and “ADHD”, and “play therapy” and
“attention deficit hyperactivity disorder”. In an effort to “review recent studies and to
enlighten the increasing interest and up to date knowledge in the field” (Kossyvaki &
Papoudi, 2016, p. 47), our review covered the decade from 2006 to 2016. The initial search
also was limited to peer reviewed journal articles. Before applying any inclusion and
exclusion criteria, initial search procedures yielded a total of 44 studies (see Figure 1).

Inclusion and exclusion criteria

Next, inclusion and exclusion criteria were applied to narrow the identified studies to
include only those that would inform the study research question. Inclusion criteria
included the following: (a) participants were medically diagnosed with ADHD or qualified
as having ADHD using a commonly used ADHD screening instrument, (b) article was
written in English, (c) a play-based intervention was the primary intervention used in the
study, and (d) reported study was a primary research study, that used one of the following
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 5

Peer-reviewed articles identified

through electronic database searching
of key terms, within 2006-2016
EBSCO-Eric: 3
EBSCO-Academic Search: 13
JSTOR: 7
PsyINFO: 27
Web of Science: 41

(n=91)

After eliminating duplicates

(n=44)

After eliminating articles that did not

identify participants with ADHD.
(n=42)

After eliminating articles that did not

focus on a play-based intervention
(n=37)

After eliminating articles that were

not written in English.
(n=32)

After eliminating articles that were

not single subject design/pre-post
experimental design
(n=7)

Figure 1. Article selection process.

designs: pre/post experimental, quasi-experimental, or single subject. There were no

specific criteria related to age of study participants in order to capture all available studies
related to play-based interventions for individuals with ADHD. To determine if a play-
based intervention was indeed implemented, this study included the definition of play-
based intervention used by the U.S. Department of Education’s What Works
Clearinghouse: play-based interventions are “practices designed to improve socio-emo-
tional, physical, language, and cognitive development through guided interactive play.
During play sessions, an interventionist uses strategies including modeling, verbal redir-
ection, reinforcement, and indirect instruction to sustain and encourage child play
activities” (U.S. Department of Education, 2012). This definition was used because it
allowed reviewed studies to include multiple types of play-based interventions. A set of
exclusion criteria also were applied: (a) the researcher was unable to determine if the
participants qualified as having ADHD, (b) the intervention did not meet the U.S.
6 H. R. CORNELL ET AL.

Department of Education’s What Works Clearing House definition of play-based inter-

ventions, or (c) the study did not use a pre/post experimental, quasi-experimental, or
single subject design.
Application of the inclusion and exclusionary criteria yielded a set of seven studies for
this review. Specifically, from the 44 articles identified from initial search procedures, two
articles were eliminated because the participants did not have ADHD; Five articles were
eliminated because they did not describe a play-based intervention; 32 articles were
eliminated because they were not written in English; and, 17 articles were eliminated
because they were not pre/post experimental, quasi-experimental, or single subject
research studies. As a last step in the search process, the reference lists of the included
articles were examined as an additional check to ensure that articles were not missed in
the search. The review of reference lists did not uncover any additional articles.
Ultimately, our search procedures yielded seven articles that were analyzed for this review.
Figure 1 provides a visual description of how the seven articles included in this review
were systematically obtained.

Data extraction and coding procedures

To analyze the identified articles, a “data extraction” form was developed by the first
author, to allow two research team members to work independently, to examine each
article and capture key information per our research questions. Data extraction forms are
often created and used when conducting systematic reviews (Kossyvaki & Papoudi, 2016).
This approach allows for data to be extracted and coded in a way that keeps the research
question central to the review. Next, each article was read by each researcher, attending to
the following: (1) author, (2) year, (3) participants, (4) dependent variables, (5) interven-
tion, (6) setting, and (7) major findings (see Table 2). Additionally, each article was
assessed in terms of the extent to which it met CEC’s methodological quality standards
for establishing evidence-based practices (Council for Exceptional Children, 2014), includ-
ing clear descriptions of a published study’s: (1) context and setting, (2) participants, (3)
intervention agent, (4) description of practice, (5) implementation fidelity, (6) internal
validity, (7) outcomes measures/dependent variables, and (8) data analysis. For each
indicator, each researcher independently rated each study as: “yes” if the study fulfilled
the indicator, and “no” if the indicator was not satisfied. In each case that an indicator was
rated as “not fulfilled” the researcher noted why. These notations facilitated discussion
between researchers at weekly meetings and contributed to obtaining 100% interrater
reliability. Studies in which all indicators were “satisfied” were considered to have met the
standards for contributing to play-based intervention as an evidence-based practice for
students with ADHD.

Interrater reliability
The two researchers conducting this study followed systematic steps to ultimately achieve
100% agreement on all of the previously described coding of each of the seven articles.
Each week, both researchers reviewed, summarized and rated the methodological quality
of 1 or 2 articles. Next, the two researchers met to share their summary and compare
coding of the methodological quality for the assigned article(s) for that week. Initially, for
all seven articles, agreement was reached on 45 of the 56 possible indicators (80%). Then,
Table 2. Summary of articles included in the review.
Author(s) and year Participants
Abdollahian et al. ● 30 participants from 7–9 years old
(2013) ● Diagnosis of ADHD made by
psychiatrist
● 15 participants in control group and
15 participants in experimental
group
Ray et al. (2007) ● 60 children with ADHD participated
● 31 were assigned to the PT (play
therapy) group and 29 were
assigned to the RM (reading moni-
toring) group.
Docking et al. (2013) ● 14 children with ADHD aged
between 5 and 10 with an average
age of 7.6. 10 males and 4 females.
Eight of the 14 children used med-
ication for ADHD.
Wilkes-Gillan et al. ● Five boys with ADHD.
(2014) ● 4 out of 5 children were on
medications.
Dependent variables Intervention and setting
● Sustained ● 45-min sessions of play therapy based on
attention CBT techniques twice weekly for four
● Working memory weeks (8 sessions total).
● Impulsivity ● Therapeutic condition (similar light, tem-
● Self-control perature and location); Community-based
● Organization
● Teacher–child ● Play Therapy group: Thirty-one students
relationship stress were assigned to the PT group, which
● ADHD symptoms consisted of 16 sessions of play therapy
scheduled over 16 weeks. Each student
received one 30-min individual CCPT ses-
sion per week.
● Reading Mentoring: Twenty-nine students
were assigned to the RM group, which
consisted of 16 sessions of reading men-
toring scheduled over 16 weeks. Each stu-
dent received one 30-min session of
individual reading mentoring per week.
● Specially equipped playrooms in a school
setting; school-based
● Pragmatic skills ● Seven 40 minute weekly sessions with a
● Problem-solving pair of occupational therapists, involving
skills both a child with ADHD and a a peer
● Social Play skills without disabilities. Therapists utilized
video feedback techniques, video-feed for-
ward techniques, and modeling of proso-
cial behaviors. Second therapist worked
with parents and provided education, sup-
port, training and feedback.
● Sydney Australia; community-based setting
● Social play skills ● The 18-month follow up assessment took
● ADHD symptoms place over one week and involved both a
parent interview and a 30 minute clinic
play session. Measured follow up effects of
a parent-delivered play-based intervention
● Clinical play room; community-based
Intervention outcomes
● Hyperactivity scores decreased
● Children participating in PT were signifi-
cantly less stressful to their teachers in
personal characteristics, specifically emo-
tional distress, anxiety, and withdrawal
difficulties.
● Children who participated in either PT or
RM exhibited a significantly positive
change in symptoms over the time of the
study with no difference between the
groups.
● Pragmatic skills did not improve.
● Prediction is the only aspect of problem-
solving skills that improved significantly
post intervention.
● Children with and without co-morbid lan-
guage difficulties significantly improved
their play skills.
● The re-examination of pre–post efficacy
findings revealed that the mean overall
post-test scores were significantly higher
JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION
than the mean overall pre-test scores
7
(Continued )
 8

Table 2. (Continued).
Author(s) and year Participants
Cantrill et al. (2015) ● Five boys with ADHD between
6–11 years old, their playmates, and
their mothers
● 4 out of 5 children were on
medications.
Dependent variables Intervention and setting
● Social play skills ● The 18 month follow up assessment took
place over two weeks and involved both a
parent interview and play observations at
home and clinic. Home visits lasted
40 minutes and clinic visits lasted 50 min-
Intervention outcomes
● Children with ADHD and their playmates
maintained gains in their social play skills
in the home and clinic setting 18 months
after the intervention
H. R. CORNELL ET AL.

utes. Measured follow up effects of a par-

ent-delivered play-based intervention
● Clinical play room and home; community-
based

Wilkes et al. (2011) ● 14 children with ADHD aged
between 5 and 10 with an average
age of 7.6. 10 males and 4 females.
Eight of the 14 children used med-
ication for ADHD.
● Social play skills ● Seven 40 minute weekly sessions with a
● Interpersonal pair of occupational therapists, involving
empathy both a child with ADHD and a typically
developing regular playmate. Therapists
utilized video feedback techniques, video-
feed forward techniques, and modeling of
prosocial behaviors. Second therapist
worked with parents and provided educa-
tion, support, training and feedback.
● Clinic; community-based
● Improvements to the social play of chil-
dren with ADHD and their playmates.
● Children with ADHD improved significantly
in four of the seven ToP items that reflect
the constructs of interpersonal empathy:
skill of sharing ideas or objects, skills of
supporting the play of others, skills of
transition between activities, and skill of
responding to play cues.

Cordier et al. (2013) ● 14 children with ADHD aged
between 5 and 10 with an average
age of 7.6. 10 males and 4 females.
Eight of the 14 children used med-
ication for ADHD.
● Pragmatic skills ● Seven 40 minute weekly sessions with a ● Children’s pragmatic language improved
pair of occupational therapists, involving significantly from pre to post intervention.
both a child with ADHD and a typically
developing regular playmate. Therapists
utilized video feedback techniques, video-
feed forward techniques, and modeling of
prosocial behaviors. Second therapist
worked with parents and provided educa-
tion, support, training and feedback.
● Therapeutic clinic; community-based
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 9

through discussion and pooled judgment during the weekly meetings, 100% agreement
was achieved on the coding of all articles.

Results
Broadly, the results obtained from our summation of the articles indicated that there are
indeed positive outcomes associated with the implementation of play-based interventions.
However, after close examination of the methodological quality of each study, it is difficult to
confirm that the research base for play-based interventions has met the standards to be
considered an evidence-based practice for students with ADHD. The following sections
describe findings from the summarization of the seven studies. Second, assessments of the
methodological quality of the reviewed studies are presented. Table 2 summarizes the
findings from the seven studies according to: 1) participants, 2) dependent variables, 3)
interventions, 4) settings, and 5) intervention outcomes. Table 3 summarizes the results of
the analysis of the methodological quality of the seven studies included in this review.

Participants
Across the seven studies, targeted participants were all diagnosed with ADHD. A total of
127 participants with ADHD were included across all studies, ranging in ages from 5 to
11 years. However, it appears that four of the seven articles included the same participants
(Cantrill, Wilkes-Gillan, Bundy, Cordier, & Wilson, 2015; Wilkes-Gillan, Bundy, Cordier,
& Lincoln, 2014; Cordier, Munro, Wilkes-Gillan, & Docking, 2013; Docking, Munro,
Cordier et al., 2013; Wilkes, Cordier, Bundy, Docking, & Munro, 2011).

Settings
The majority of these studies (n = 5) were conducted in a therapeutic, community-
based clinic. One study was conducted in a therapeutic, community-based clinic with
a home intervention component and one study was conducted in a school-based
setting.

Dependent variables
The studies in this review examined either social play skills (n = 3) or ADHD symptoms
(n = 3), which included impulsivity, self-control, organization, working memory, and
sustained attention. Two studies examined pragmatic language skills. Broadly, pragmatic
skills refer to the appropriate use of language and social skills in a given context (Bruce,
Thernlund, & Nettelbaladt, 2006; Rapin & Allen, 1993). Teacher–child relationship stress,
problem solving skills, and interpersonal empathy were all examined separately and in
only one study each.

Interventions
A total of three unique play-based interventions were described across the seven studies in
this review. The first was a clinic-based intervention that consisted of eight (twice weekly)
10 H. R. CORNELL ET AL.

Table 3. Coding of methodological quality using CEC standards for evidence-based practice.
Wilkes-
Docking Ray Gillan Cantrill Wilkes Cordier
Abdollahian et al. et al. et al. et al. et al. et al.
et al. (2013) (2013) (2007) (2014) (2015) (2011) (2013)
1.0. Context and setting. The study provides Yes No Yes Yes Yes No No
sufficient information regarding the critical
features of the context or setting.
2.0. Participants. The study provides sufficient No Yes Yes Yes Yes Yes Yes
information to identify the population of
participants to which results may be
generalized and to determine or confirm
whether the participants demonstrated the
disability or difficulty of focus.
3.0. Intervention agent. The study provides No Yes Yes Yes Yes Yes No
sufficient information regarding the critical
features of the intervention agent.
4.0. Description of practice. The study Yes Yes Yes No Yes Yes Yes
provides sufficient information regarding the
critical features of the practice (intervention),
such that the practice is clearly understood
and can be reasonably replicated.
5.0. Implementation fidelity. The practice is No No No No No No Yes
implemented with fidelity.
6.0. Internal validity. The independent No No No No No No No
variable is under the control of
experimenter. The study describes the
services provided in control and comparison
conditions and phases. The research design
provides sufficient evidence that the
independent variable causes change in the
dependent variable or variables. Participants
stayed with the study, so attrition is not a
significant threat to internal validity.
7.0. Outcome measures/dependent No Yes Yes Yes No Yes Yes
variables. Outcome measures are applied
appropriately to gauge the effect of the
practice on study outcomes. Outcome
measures demonstrate adequate
psychometrics.
8.0. Data Analysis. Data analysis is Yes Yes Yes Yes Yes Yes Yes
conducted appropriately. The study reports
information on effect size.

45-min sessions of play therapy that were based on cognitive behavioral therapy (CBT)
principles. CBT principles refer to the act of cognitive restructuring in which the therapist
and student work together to change thinking patterns to improve behavior and overcome
obstacles. The general assumption is that an individual’s mood is directly related to his or
her patterns of thought. The CBT approach is educational in that the therapist typically
works with students through structured learning experiences (Beck & Dozois, 2011).
The second intervention was a school-based intervention in which individuals partici-
pated in one child-centered play therapy (CCPT) 30-min session per week over 16 weeks.
CCPT is described as a person-centered intervention in which the child and the therapist
form an interpersonal relationship through the process (Jayne & Ray, 2015). The concept
of person centered intervention is derived from Carl Roger’s (1959) person-centered
theory in which the therapist is nondirective and assumes an empathetic, relational
approach that empowers and motivates the student in the learning process (Rogers,
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 11

Lyon, & Tausch, 2013). In this process, the child will freely play with the toys that the
therapist provides. At the same time, the therapist will facilitate the child’s play to support
the child to fully express himself or herself through play (Ray, Armstrong, Balkin, & Jayne,
2015).
The last intervention was also a clinic-based intervention. However, this intervention
was conducted by two occupational therapists and included seven 40-minute weekly
sessions with a pair of occupational therapists, and involved both a child with ADHD
and a playmate without ADHD. The primary therapist worked with the child and used
edited video footage of the child’s social play from the previous week to discuss segments
of past performance. In addition, the therapist used video-feed forward techniques to
facilitate a problem-solving discussion with the child to help them with strategies for
change and skill development. The second therapist worked with parents and provided
education, support, training, and feedback. More specifically, parents observed all play-
room sessions through a one-way mirror, completed weekly play tasks and reviewed their
weekly take-home copy of the self-modeling DVD with their child before the next session
(Wilkes et al., 2011).

Intervention outcomes
Positive intervention outcomes were reported in each of the seven articles in this review,
which include improvements in, ADHD symptoms, teacher stress, prediction as it relates
to problem-solving skills, social play skills, interpersonal empathy, sharing ideas or
objects, and transition skills. These outcomes are described in this section, organized by
intervention type.
For the clinic-based intervention that consisted of eight (twice weekly) 45-min sessions
of play therapy based on CBT principles (Abdollahian et al., 2013), findings indicated
improvements in hyperactivity scores, which are related to improvements in sustained
attention, working memory, impulsivity, self-control, and organization. However, when
children with ADHD were compared to their play partners without disabilities there were
not any significant differences, indicating that both groups of students benefited from the
intervention in similar ways.
In the one play-based intervention study that took place in a school setting,
students participated in one child-centered play therapy (CCPT) 30-min session per
week over 16 weeks (Ray, Schottelkorb, & Tsai, 2007). Play therapists were doctoral-
level and master’s level counseling students who had received at least two courses in
play therapy and had previously been supervised by a counseling faculty member
certified in play therapy. The findings from this study suggested that children parti-
cipating in the play-based intervention were significantly less stressful to their teachers
in terms of personal characteristics, specifically emotional distress, anxiety, and with-
drawal difficulties. However, children who participated in the play-based intervention
and those in the control condition who participated in only reading mentoring had
positive changes in ADHD symptoms over time with no significant differences
between groups. Given that both groups of students had improvements in ADHD
symptoms, this suggests that it there is some other unique feature that is similar to the
play-based intervention and reading mentoring program that is likely to be the causal
agent for these changes.
12 H. R. CORNELL ET AL.

The third intervention type, which involved 40-minute weekly sessions with a pair of
occupational therapists (Cantril et al., 2015; Cordier, Munro, Wilkes-Gillan, & Docking,
2013; Docking et al., 2013; Wilkes et al., 2011; Wilkes-Gillian et al., 2014) also yielded
some positive effects. Specifically, across five studies, this intervention demonstrated
improvements in the prediction aspect of problem-solving skills, social play skills, inter-
personal empathy, skill of sharing ideas or objects, skill of supporting the play of others,
skill of transition between activities, and skill of responding to play cues. However, results
were inconclusive in terms of the extent to which this play-based intervention improves
pragmatic language because improvements were indeed seen in one study, while improve-
ments were not seen in another. Similar to other studies in this review, both students with
and without ADHD symptoms showed similar degrees of improvements. Additionally,
follow up studies suggested that social play skills were maintained at 18 months post-
intervention.

Assessments of methodological quality

None of the seven studies met all of the quality indicators outlined by CEC. One study met
6 of the 8 quality indicators (75%); five students met 5 of the 8 quality indicators (62%);
and one study met three indicators (37%) (see Table 3). Moreover, across all seven articles,
only four studies provided sufficient information related to the context or setting, six
studies provided sufficient information about participants, five studies provided the
necessary information about the intervention agent, five studies provided a sufficient
description of the intervention, and only one study provided evidence that the interven-
tion was implemented with fidelity. None of the studies met the criteria for internal
validity; whereas five studies adequately described outcome measures/dependent variables;
and six studies reported information about effect size.
In sum, internal validity was a problem in all of these studies mainly because most of
the authors did not provide an adequate control group comparison condition. The lack of
an appropriate control condition makes it difficult to attribute positive findings from these
studies to the play-based intervention treatment. In fact, in most of these studies it was
difficult to confidently assess the impact of the intervention specifically for students with
ADHD. Although, in some cases the effects for students with ADHD and their playmates
were similar, which based on these findings, it seems that play-based interventions do not
seem to have a different or enhanced effect for students with ADHD when compared to
students without disabilities.

Discussion
The purpose of this systematic review was to identify and assess the current state of the
evidence for using play-based interventions to improve outcomes for students with
ADHD, while also documenting the methodological quality of existing studies. Findings
suggest that the existing body of literature on this topic suffers from several limitations,
including the lack of methodological rigor. Thus, despite the largely positive findings
attributed to play-based interventions, as reported in this set of research articles, we are
forced to conclude that currently there is insufficient evidence to confidently rate play-
based intervention as an evidence-based practice for students with ADHD. However,
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 13

although more research is needed, we also suggest that play-based interventions appear to
be a promising approach to use with at least some students with ADHD. In our discussion
that follows, we examine these findings as they point to some important implications for
researchers, school-based occupational therapists, and those who train them.
First, findings from our review indicate that the study of play-based interventions for
students with ADHD may not be a prominent practice in the United States (U.S.), as
compared to other countries. In fact, the majority of available studies were conducted in
other countries. We speculate that, compared to the U.S., treating or managing ADHD
symptoms is handled different in other countries, where there appears to be more use of
play-based approaches. If this is indeed accurate, we further speculate that it likely follows
that more resources are available in these other countries, both to use these interventions
as well as to fund research examining the use of play-based interventions for young people
with ADHD. Obviously, more can be understood if similar research is conducted in the
United States.
Another finding from our work that may warrant further consideration is that only one
of the identified studies was conducted in a school-setting. This makes it difficult to fully
discern the effectiveness of using play-based interventions in schools for students with
ADHD. As noted, the lack of research in this context may reflect the scarcity of resources
available for these interventions. Historically, although it has been school-based mental
health professionals who were expected to implement play-based interventions (Cummins
et al., 2013; Ray, Armstrong, Warren, & Balkin, 2005), researchers also note that school-
based therapists, social workers, and counselors are typically overwhelmed with large
caseloads and, moreover, many schools continue to lack dedicated mental health profes-
sionals (Cummins et al., 2013; Ray et al., 2005). An alternate explanation may be that
many schools tend to operate from more behaviorist perspectives when responding to the
behavior challenges of students with ADHD (Daley et al., 2014), whereas play-based
interventions require school-professionals to operate from more person-centered view-
points (Lin & Bratton, 2015). Thus, shifting underlying philosophies currently operating
in schools may be necessary if schools are to more widely adopt play-based approaches for
this population of students.

Implications for school-based occupational therapists

The American Occupational Therapy Association (AOTA) recognizes the role of the
school-based occupational therapist to be one that supports students’ ability to participate
in desired daily school activities or “occupations”, such as positive behavior and social
skills. In schools, occupational therapy services are typically only available for students
with ADHD who also qualify for special education services, with the need for OT
determined through the individualized education program planning process (AOTA,
2016). Historically, school-based occupational therapy interventions often have been
relegated to sensory integration and the targeting of educational areas, such as hand-
writing (Benson, Elkin, Wechsler, & Byrd, 2015). For example, for students with ADHD,
interventions have traditionally focused on improving in-seat behavior, such as through
the use of therapy balls and legible word productivity (Schilling, Washington, Billingsley,
& Deitz, 2003). In light of this, findings from this study support the need for further
14 H. R. CORNELL ET AL.

discussion about expanding the role of school-based OTs to implement play-based inter-
ventions, specifically for students with ADHD.
Given the promising findings from this review, we also contend that play-based
interventions may have an important but underused role in reducing ADHD symptoms,
developing social competence, and increasing positive behavior among school-aged (5–
11 years) children with ADHD. The primary interventionists in several of the articles
examined in this review were occupational therapists (Cordier et al., 2013; Docking et al.,
2013; Wilkes et al., 2011). This confirms that occupational therapists can indeed be
prepared to support the needs of students with ADHD through play-based intervention,
which is also consistent with their professional role (American Occupational Therapy
Association, 2016). As such, expanding the role of the school-based occupational therapist
to one that regularly delivers play-based interventions, similar to what was found in this
review, might prove to positively impact the school functioning of this population of
students. For example, play-based interventions delivered in schools would increase the
number of social opportunities students have to develop their social competence. This
could lead to more friendships, reduced social isolation, improved school functioning, and
long-term development.
Recognizing this and expanding the role of school-based occupational therapists to one
that more regularly delivers play-based interventions might also serve to assist under-
resourced schools. For example, expanding the role of the school-based OTs may help to
improve the social competence and behavioral needs of students with ADHD in schools
where there are no mental health professionals. Historically, albeit limited, play-based
interventions have been delivered in schools by school mental health professionals who
work with students individually or in small groups to promote social and academic growth
through play (Bratton, 2010; Trice-Black, Bailey, & Kiper Riechel, 2013). Despite the
intended uses of play-based interventions, lack of funding often limits the number of
mental health professionals who are available to work in schools to implement interven-
tions, including play-based approaches (Cummings et al., 2013). Increased recognition will
be needed to support the use of school-based OTs as school professionals who have
specialized knowledge in supporting students’ school occupations through play-based
interventions.
Expanding the role of the school-based OT will certainly require realigning school
resources, rethinking of traditional roles, as well as providing additional training and
supports. In fact, some studies have emphasized the need for enhanced training so various
non-teaching school professionals can more effectively support the needs of students with
emotional disturbances (Bonnard & Anaby, 2016). We argue that such re-visioning could
and should include students who have ADHD. Moreover, occupational therapists have
reported feeling like they not only lack knowledge, but have confusion about their role,
which likely has led to their underutilization in schools to assist in confronting the
complex needs of some populations of students, such as those who have ADHD
(Kennedy & Stewart, 2012). Obviously, this also has direct implications for those who
train and/or provide professional development for occupational therapists, including
universities/higher education, and school districts that employ these professionals. We
therefore also recommend the provision of educational experiences that expand the OT
role to one that implements play-based interventions for students with ADHD. Finally,
even if occupational therapists possess the necessary training to implement play-based
 JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 15

interventions in schools, students with ADHD likely will receive such services at school
only if they have an IEP or 504 plan. Thus, it will also be important to educate teachers
and social service providers about the array of supports that school-based OTs might offer.
This may require that occupational therapists work to advocate for and educate others
about research supporting play-based interventions as a promising practice for positively
influencing outcomes for students with ADHD.

Recommendations for further research and conclusion

Not surprisingly, we end with a call for more research. It appears that many of the studies
included in this review may have used similar participants. Replication of findings across a
wider variety of unique participants and settings is needed to confidently make conclu-
sions about the effectiveness of an intervention and its generalizability from research to
practice (Slocum, Detrich, & Spencer, 2012). As such, it is difficult to identify play-based
interventions as an evidence-based practice without the ability to generalize across settings
and participants. Future research should also examine play-based interventions conducted
specifically by OTs in schools. Research conducted in school settings could allow for better
generalizability of findings specifically for OTs who work in schools. In addition, such
studies should examine both challenges and facilitators associated with successfully
implementing play-based interventions in schools. This is critical because play-based
interventions delivered in the school setting have the potential to eliminate some common
barriers to non-school interventions, such as transportation and cost of services, both of
which are associated with service delivery in the more commonly used community clinic-
based settings. Obviously, future studies also should ensure that the research meets the
quality indicators for evidence-based practice, as put forth by the Council for Exceptional
Children, so that the findings can be used to contribute to building an evidence base that
meets specific practice standards in education. Thus, we recommend, for example, that
future studies include control groups so that the effects of the intervention can be better
attributed to the implementation of the play-based intervention for students with ADHD.
Finally, even with the methodological concerns uncovered in this review, we reiterate
that findings are promising, as play-based interventions generally appear to have the
potential to improve the social skills of students with ADHD (Abdollahian et al., 2013;
Cantrill et al., 2015; Docking et al., 2013; Wilkes et al., 2011; Wilkes-Gillan et al., 2014), as
well as relationships between student and teacher (Ray et al., 2007). Because students with
ADHD often experience problems interacting socially with others (Wilkes-Gillan et al.,
2014) and student–teacher relationships can be strained (Mrug et al., 2012; Crum,
Waschbusch, & Willoughby, 2016), such situations too often lead to negative school
experiences for these students (Schottelkorb & Ray, 2009). Although only one study in
this review was conducted in a school setting, we think that the promising findings overall
have implications for school-based occupational therapists. Therefore, we end by again
encouraging schools to rethink the role of school-based occupational therapists to better
use their expertise to support students with ADHD for improving social and academic
competence, leading to more comprehensive school engagement (American Occupational
Therapy Association, 2016).
16 H. R. CORNELL ET AL.

Conflicts of interest
The authors reported they had no conflicts of interest related to this study or its publication.

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