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______________________________________________________________________________________________________________________________Report Information from ProQuestDecember 03 2014 22:03_______________________________________________________________目录1. Empathy in the Play of Children with Attention Deficit Hyperactivity Disorder (1)第 1 个文档，共 1 个Empathy in the Play of Children with Attention Deficit Hyperactivity DisorderProQuest 文档链接摘要: Many children with attention deficit hyperactivity disorder (ADHD) have serious social and peer difficulties that can lead to adverse outcomes in adolescence and adulthood. Play provides a natural context to explore those interactional problems. This study aimed to examine the similarities and differences in play behavior of children as having ADHD and typically developing children. Participants were children (aged 5 to 11 years) diagnosed as having ADHD ( n = 112) and typically developing peers (n = 126) who were matched based on age, ethnicity, and gender. The Test of Playfulness (ToP) was used to measure play. Children with ADHD performed similarly to typically developing peers on ToP items that related most directly to the primary symptoms of ADHD but scored significantly lower on several ToP social items; however, they also scored higher on one difficult social item and no differently on two others, suggesting that the problems may be developmentally inappropriate lack of empathy rather than simply poor social skills.Keywords: playfulness, decentering, social problems链接: CALIS e&#24471;&#25991;&#29486;&#33719;&#21462;,UNICAT&#32852;&#21512;&#30446;&#24405;(&#21002;&#21517;)全文文献: Attention deficit hyperactivity disorder (ADHD) is characterized by developmentally inappropriate levels of inattention, impulsivity, and hyperactivity that cause impairment in day-to-day life. ADHD is associated with a range of behavioral problems (American Psychiatric Association, 2000 ).Many children with ADHD have serious social difficulties that may continue throughout adolescence and adulthood (Barkley, 2006a ; Schachar, 1991 ; Wood, 1995 ). Peer rejection and few friends are predictive of adverse outcomes in adolescence and adulthood. These may include comorbid psychiatric disorders, school drop-out, development of externalizing behaviors, and antisocial behavior, which in turn may lead to adjustment problems and difficulties in adult relationships ( Crick &Dodge, 1994 ; Erdley &Asher, 1999 ; Hoza, Mrug, Pelham, Greiner, &Gnagy, 2003 ; Ollendick, Weist, Bolden, &Green, 1992 ).Currently, treatment outcomes for children with ADHD are often less than satisfactory. Despite medication, which is the most common treatment, many children continue to experience social and peer relationship problems (Hechtman et al., 2005 ; MTA Cooperative Group, 1999, 2004 ). Children from the Multimodal Treatment Study of ADHD were found to remain significantly impaired in their peer relationships despite evidence of improvements in other areas (Hoza, 2007 ; MTA Cooperative Group, 1999, 2004 ). Furthermore, psychoactive medication for ADHD was not associated with having more friends or being better accepted or less rejected (Bagwell, Molina, Pelham, &Hoza, 2001 ; MTA Cooperative Group, 1999, 2004 ; Mrug, Hoza, &Gerdes, 2001 ).Professionals working with children with ADHD commonly use play to explore behavioral and social difficulties. Furthermore, play provides a natural context to address the interactional problems that children with ADHD may experience. Given the importance of play to social development, surprisingly little published research exists on the impact of ADHD on play. The limited research suggests that children with ADHD are less playful ( Leipold &Bundy, 2000 ), perform more poorly on aspects of play that are influenced by hyperactivity, impulsivity, and inattention ( American Psychiatric Association, 2000 ; Barkley, 2003 ), and have difficulties with the social dimensions of play (Hechtman et al., 2005 ; MTA Cooperative Group, 1999, 2004 ).The reason for the limited research on play could be explained in part by the difficulties in defining play, which remains an elusive concept (Rubin, Fein, &Vandenberg, 1983 ). Although there is some disagreement about the exact characteristics that comprise play, play is commonly defined by the characteristics that separate it from non-play. Neumann (1971 ) proposed a simple list: intrinsic motivation, internal control, and suspension of reality. After the work of Bateson (1971, 1972 ), Bundy (e.g., Bundy, 2004 ; Skard &Bundy, 2008 ) proposed the addition of a fourthcharacteristic: framing (reading and interpreting social cues). When play is defined by these four traits, current literature provides some indication of how the characteristics inherent to ADHD and the elements of playfulness interact.For the purposes of this study, play was defined as a transaction between the individual and the environment that is intrinsically motivated, internally controlled, and free of many of the constraints of objective reality and skills related to framing (giving and responding to cues) ( Bateson, 1971, 1972 ; Skard &Bundy, 2008 ). Play manifests in children as playfulness (i.e., the disposition to play) (Bundy, 2004 ; Neumann, 1971 ).Using the Test of Playfulness (ToP) to operationalize the definition of play, we set out to explore the similarities and differences in the play of children with ADHD compared with typically developing children. We tested the following hypotheses:Hypothesis 1: The mean overall ToP score of children with ADHD will be significantly lower than that of typically developing peers.Hypothesis 2: The mean scores of children with ADHD will be significantly lower than those of typically developing peers on ToP items that reflect the primary symptoms of ADHD (inattention, hyperactivity, and impulsivity).Hypothesis 3: The mean scores of children with ADHD will be significantly lower than those of their typically developing peers on items that reflect the social dimensions of play.MethodParticipantsThis study compared 238 children between the ages of 5 and 11 years who were divided into two groups. Group 1 consisted of children diagnosed as having ADHD who were paired with typically developing playmates (one child with ADHD and one typically developing child in each observation) and group 2 consisted of typically developing children who were paired with a playmate who was also typically developing (two typically developing children in each observation). All playmate pairs were familiar with one another. Children in group 2 and the playmates of children with ADHD in group 1 were known not to have ADHD as defined by the Diagnostic and Statistical Manual of Mental Disorders , 4th edition (DSM-IV) criteria for ADHD. Overall, children who were not proficient in English were excluded because use of English is necessary for interpreting the ToP by an English speaking rater. This investigation is part of a larger study; only the children with ADHD in group 1 (not their playmates) and all children in group 2 will be discussed.Children With ADHD. This group included 112 children with ADHD recruited from district health boards and pediatricians' practices in Auckland, New Zealand. Diagnostic procedures were designed to ensure high levels of diagnostic accuracy and to minimize the inclusion of borderline cases (i.e., cases just failing to reach criteria on the DSM-IV) and cases diagnosed as something other than ADHD were deemed the primary diagnosis.To be included in the study, children had a formal diagnosis of ADHD made by a psychiatrist or pediatrician according to DSM-IV criteria. Furthermore, they were included if they had conditions known to be comorbid to ADHD, such as learning disorders, oppositional defiant disorder, conduct disorder, anxiety disorder, and mood disorder--provided that ADHD was the primary diagnosis. They were excluded if they had other major neurodevelopmental or psychiatric disorders, such as Autism spectrum disorders, intellectual disabilities, movement or tic disorders, and organic brain syndromes.Additionally, we included children with ADHD who were receiving the short-acting forms of methylphenidate given that their duration of action is 3 to 5 hours (American Academy of Child and Adolescent Psychiatry, 2007 ; Physicians' Desk Reference, 2007 ). We excluded those taking the long-acting forms or atomoxetine and children who took medication for comorbid conditions. Parents or guardians were requested not to administer medication prescribed for ADHD on the day of the assessment because we were interested to observe how ADHD affects play without the effects of medication. Each of these children invited a playmate of a similar age to the play session.Typically Developing Children (Control Group). This group included 126 children. They were recruited fromprofessional networks such as local schools and from families of health services employees. For the purpose of this article, a typically developing playmate was defined as a child who did not have ADHD (i.e., scored below the clinical cut-off for any of the Conners' Parent Rating Scales-Revised [CPRS-R] subscales and DSM-IV scales) and for whom no concerns had been raised about development by a teacher or health professional. The demographic information from the participants and their primary caregivers is summarized in Table 1. To assist with interpretation of the ToP results, the mean CPRS-R subscale scores are summarized in Table 2. The children with ADHD and the typically developing children playing together were matched by age groups (5-6, 7-8, and 9-11 years), sex, and ethnicity. Data on socioeconomic status were gathered, but it was not possible to match the groups a priori for socioeconomic status.InstrumentsThe ToP (Bundy, 2004 ) was used to measure the children's play. It is a 29-item observer rated instrument that can be administered to any individual between the ages of 6 months and 18 years. Each item is rated on a 4-point (0-3) scale. Scores reflect either extent (proportion of time), intensity (degree of presence), or skillfulness (ease of performance). The ToP measures the concept of playfulness as a reflection of the combined presence of four elements contributing to a single (unidimensional) construct of playfulness: perception of control, freedom from constraints of reality, source of motivation, and ability to give and read social cues. Although the ToP was designed to represent a theoretical conceptualization of playfulness comprising multiple elements, playfulness is a single construct; thus, it is not feasible to analyze data by the four elements ( Bundy, 2004 ). One overall scaled score is calculated with a mean of 50 and a standard deviation of 10. Table 3 provides item descriptions.The ToP is administered in an environment that is supportive of play and has evidence for excellent inter-rater reliability (data from 96% of raters fit the expectations of the Rasch model), construct validity (e.g., data from 93% items and 98% of people fit Rasch expectations) ( Bundy, Nelson, Metzger, &Bingaman, 2001 ), and moderate test-retest reliability (e.g., intraclass correlation 0.67 at p <.01; Brentnall, Bundy, &Kay, 2008 ). All play sessions were video recorded for detailed analysis after observation using the ToP.The CPRS-R was administered for all children in the sample. The CPRS-R is a paper-and-pencil screening questionnaire completed by the parents or guardians to assist in determining whether children between the ages of 3 and 17 years have signs and symptoms consistent with the diagnosis of ADHD. The CPRS-R has evidence of excellent reliability (international consistency reliability 0.75-0.94) and construct validity (to discriminate ADHD from the non-clinical group: sensitivity = 92%, specificity = 91%, positive predictive power = 94%, negative predictive power = 92%) ( Conners, 2004 ; Conners, Sitarenios, Parker, &Epstein, 1998 ). The CPRS-R is one of the assessment tools most commonly used throughout the world in the diagnosis of ADHD (Hale, How, Dewitt, &Coury, 2001 ); it produces subscale scores, expressed as t scores, ranging between 0 and 100.For the children with ADHD, clinical cut-off scores from the CPRS-R were used to confirm the diagnosis of ADHD and to screen for comorbid conditions (e.g., oppositional defiant disorder and anxiety) in addition to the diagnosis made by the pediatrician or psychiatrist. The CPRS-R was also used for the playmates and children in the control group to ensure the absence of ADHD. The mean scores of the CPRS-R subscales (cognitive problems, oppositional behavior, anxious or shy, perfectionism, social problems, psychosomatic, emotional lability, and behavioral problems) were used to assist in the interpretation of ToP findings.ProcedureEthical approval was obtained from the University of Sydney Human Ethics Research Committee and the Northern Y Regional Ethics Committee, New Zealand. For convenience of the families and to ensure familiarity of the play environments, data for the two groups were gathered in different but equivalent settings. The environment where data were gathered for children with ADHD was a playroom set up specifically for the assessment in a clinical setting where the children with ADHD came regularly for assessment or intervention. The play environment for children in the control group was a designated play area at the respective schools that children in the control group attended.According to Bundy (2004 ), the environment should be one in which the child feels physically and emotionally safe to increase chances for spontaneous and intrinsically motivated play behavior to occur. The categories of the Test of Environmental Supportiveness (TOES) were used as guidelines for establishing play spaces with the maximum chance of promoting play. The TOES operationalizes the ways in which four aspects of the environment influence players' motivation to play: playmates, objects, play space, and the sensory environment ( Skard &Bundy, 2008 ).The toy selection catered to gender differences, the age range of the children, and their likely motivations for engaging in free play. A diversity of play materials was present in each room to support a range of play. The same toys were present during all play sessions and the children were allowed to choose play materials and activities.Approximately 60% of the playmates of children with ADHD were siblings because that proportion of the children with ADHD identified that they did not have another usual playmate. The assessor tried to make participants feel at ease prior to the interactive free play session by introducing them to the play situation. Participants were instructed that they could play with any of the toys in the playroom for 20 minutes and that they should ignore the assessor who was present in the play room. The assessor was as unobtrusive as possible and had been instructed to not intervene unless a child was in danger. When children attempted to interact with the assessor, the assessor's response was neutral.A single experienced rater assessed all of the children from the videotapes. Prior to scoring, the rater was calibrated on the ToP, which means the consistency of her ratings was compared with that of hundreds of other raters in a larger ToP sample (n >3,000 observations); her calibration results demonstrated that she is a reliable rater because her goodness of fit statistics were within an acceptable range (see Facets generated goodness of fit statistics in the Data Analysis section). To ensure that her scores did not drift, the rater rescored approximately 20% of the videotapes, which were randomly selected. Data from both test administrations were analyzed with Facets software (see Data Analysis section); scores for each child were compared for time 1 versus time 2 and found to be equivalent because the overall scores differed by more than the standard error of measurement. The rater did not participate in any other aspect of the study and was blinded to the purpose of the study to minimize bias.Data AnalysisTo attain interval level scores for each participant, raw ToP scores were subjected to Rasch analysis using the Facets program (version 3.62.0; Linacre, 2007 ). The resulting measure scores were then entered into t tests used to compare differences between the means of the groups using SPSS version 15 (SPSS Inc., Chicago, IL). Differences between means of the groups are regarded as significant at t ≥1.96 and t ≤-1.96 (Coakes &Steed, 2007 ). Prior to further calculations, however, we examined the goodness of fit statistics for people and items to ensure that they were within an acceptable range set a priori (MnSq <1.4; standardized value ≤2; Bond &Fox, 2007 ); this ensured that the measure scores were true interval level measures.The Facets program also checks for bias specifiers between the model and specifications. Bias interaction analysis, also called differential item functioning, was used to examine the ToP items to see whether the items have significantly different meanings for the two groups, indicated by any significant differences in how children performed on each ToP item for each diagnostic group (ADHD vs. control). Rasch bias interaction statistical procedures identify items that do not maintain stable difficulty parameters across population subgroups ( Wendt&Surges-Tatum, 2005 ). This enables the measurement of bias interaction for each ToP item that contributes toward the statistical model (Linacre, 2007 ). The specified bias interaction is estimated for all data (not just the data matching that particular model).Because the children with ADHD in group 1 were compared with pairs of typically developing children in the control group, the children in the control group observations were weighted at 0.5 to address any potential bias in the analysis, enabling pairwise analysis ( Linacre, 2007 ). Pairwise bias interaction is used to correct for estimationbias when the data correspond to pairwise observations (such as dyads playing together). The pairwise bias interaction for each item and diagnostic group is expressed as a t value.Bias interaction analyses generated by the Facets program also can be used to ensure equivalence of the groups with respect to potentially confounding variables. We tested the effects of nine such variables: (1) sex, (2) age (in three groups: 5-6, 7-8, and 9-11 years), (3) ethnicity, (4) socioeconomic status, (5) younger versus older sibling playmates, (6) age difference between playmate pairs, (7) sibling versus peer playmates, (8) clinically significant oppositional defiant disorder symptoms versus non-clinically significant oppositional defiant disorder symptoms, and (9) clinically significant anxiety symptoms versus non-clinically significant anxiety symptoms. All significance p levels were .05 or less.ResultsPrior to any other analyses, we examined the goodness of fit for data from the items and children. Fit statistics from all but one item (Feels Safe) were within the accepted range; we removed that item because it seemed to reflect an artifact of the setting. Data from four children were outside the range, so we ran all analyses both with and without those children and, finding no differences, retained their data.We then tested for the effects of the confounding variables listed above. None of the results was significant (t <1.96; p <.05). We interpreted this to mean that none of the confounding variables that we tested (e.g., comorbid oppositional defiant disorder or anxiety) accounted for the observed differences.Hypothesis 1The hypothesis that the mean overall ToP score for children with ADHD will be significantly lower than that of typically developing peers was supported. A t test for independent samples revealed that the children with ADHD were less playful than the typically developing children (ADHD mean measure score = 1.09; ADHD standard deviation = 1.28; control mean measure score = 1.99; control standard deviation = 0.82; t = -13.9; p <.01; df = 125). The results of the pairwise bias interactions comparing the performance of the groups on each item are shown in Table 3. In the remainder of the discussion, the ToP item numbers, as shown in Table 3, are used in brackets for reference.Hypothesis 2The hypothesis that the mean scores of children with ADHD will be significantly lower than those of typically developing peers on ToP items that reflect the primary symptoms of ADHD (inattention, hyperactivity, and impulsivity) was not supported. By definition, six ToP items relate directly to the primary symptoms of ADHD. These items include the skill to initiate new activities (1); intensity of interaction with objects (6); skill to modify activities (8); extent of being engaged (21); intensity of engagement in an activity (22); and ability to persist with an activity (24). Table 4 provides a summary of the descriptions of the ToP items and their relationship to the characteristics of the primary symptoms of ADHD. Children with ADHD did not perform significantly more poorly on any of these six items.Hypothesis 3The hypothesis that the mean scores of children with ADHD will be significantly lower than those of their typically developing peers on items that reflect the social dimensions of play was partially supported. Eight ToP items represent the social dimension of play (i.e., items that require social interaction to be scored): skill to initiate (1), negotiate (2), share (4) and support the play of others (5); extent of social play (10); intensity of social play (11); and skill of social play (12) and responding to cues (29). Children with ADHD performed significantly more poorly on five of the eight social items: shares (4); support (5); intensity (11) and skill of social play (12); and skill in responding to cues (29) (Table 3). However, of the remaining three social items, children with ADHD performed significantly better than typically developing children on skill to negotiate (2). There was not a significant difference for the skill to initiate (1) or extent of social play (10).DiscussionWe set out to examine the similarities and differences in the play of children with ADHD compared with that oftheir typically developing peers. In particular, we attempted to determine whether children with ADHD are less playful compared with typically developing peers, unravel the impact of primary symptoms of ADHD (i.e., inattention, hyperactivity, and impulsivity) on the play of children with ADHD, and examine the social concomitants of ADHD as manifested in play. Although, as expected, we found overall differences between the groups, the details of what we found are notable for both what we expected but did not find and what we discovered unexpectedly.Surprisingly, none of the ToP items that relate directly to the primary symptoms of ADHD differed significantly between children with ADHD and typically developing children, suggesting that the primary symptoms of ADHD did not account for the overall differences and did not appear to impair the play of children with ADHD in a directly observable manner, at least as measured by the ToP. This finding may be explained by the play situation, which was designed to be particularly appealing to increase the chances that play occurred. Apparently, the high level of appeal offset the primary symptoms of ADHD ( Diamond, 2005 ).Children with ADHD had difficulty in the preponderance of ToP social items (5 of 8), thus underscoring the social difficulties they experience. These differences could not be attributed to the fact that more than half of the children with ADHD identified that they did not have friends and thus chose to play with a sibling. Although there was no observable difference in the proportion of time children with ADHD and typically developing children interacted with playmates, the intensity of that interaction was significantly less for children with ADHD and they were less skilled at social play compared with typically developing children in the control group.Similarly, children with ADHD gave clear social cues (27 and 28), but were significantly less able to respond to others' cues than typically developing peers (29). Taken together, these findings suggest that children with ADHD seek out social interaction as much as typically developing children (11) do, but they struggle as the transaction becomes more intense (12), perhaps because they find responding to playmates' cues (29) more difficult than typically developing peers do (responding to cues is, for most children, an easy item--in the bottom 20% overall when ToP items are ranked hardest [top] to easiest [bottom]).This finding is supported by the mean score children with ADHD have on the CPRS-R social problems and general behavioral problems subscales (76.0 and 73.0, respectively), which are above the clinical cut-off. (Note: Higher scores indicate greater difficulty.) However, compared with children in the control group, children with ADHD performed better on skill to negotiate (2) and there were no significant differences for initiates (1) and extent of social play (10), suggesting that poor social skills may not fully explain the difficulties they experience in play.The ToP items on which children with ADHD were significantly less playful than the typically developing children (Table 5) are primarily reflective of poor social skills. One might stop at that simple explanation--except that the children with ADHD also were better at negotiating (2) and performed similar to children in the control group on initiating play (1), two reasonably high-level social skills. Taken collectively, the items on which the children with ADHD were both less skilled and the ones in which they were as skilled or more skilled is reminiscent of another construct--interpersonal empathy.The term empathy implies both affective and cognitive dimensions (Feshbach, 1997 ; Strayer, 1987 ). Empathy, as described by Feshbach and applied to the ToP items (see Table 5 where ToP items were matched with the corresponding components of the empathy construct), comprises the ability to discriminate and identify the emotional states of another (ToP item 29), the capacity to take the perspective or role of the other (ToP items 4, 9, and 14), and the evocation of a shared affective response (ToP items 5, 11, and 12). The scoring criteria for low ToP scores (as reflected in Table 5) are derived directly from the ToP manual ( Bundy, 2004 ). Proposed explanations are offered for the preponderance of those low scores of children with ADHD.Lack of empathy is characteristic of all young children (Piaget, 1962 ). As children mature during their early school years, empathetic thinking and responding evolves and children learn that others have ideas and views different from their own (Frith &De Vignemon, 2005 ). By early school age (the age of the children in this study), children are betterable to take on others' viewpoints and are less occupied with their own viewpoint; they become more decentered.Our results suggest that children with ADHD have difficulty in this regard, as evidenced by their difficulties responding to others' play cues, sharing resources and ideas, and supporting others' play, and their superficial or destructive interactions with other players. Observed within the context of play, their lower level of interpersonal empathy manifests because the children are self-absorbed and focused on having their own play needs met. They negotiate to have their play needs met and give social cues, but do not always respond to others' cues. Although they may use skills typically associated with highly skillful play such as playful mischief, they often use these strengths primarily to achieve their own goals. Unsurprisingly, playmates of children with ADHD often describe them as domineering and controlling ( Barkley, 2006a ; Melnick &Hinshaw, 1996 ).We conclude that children with ADHD seem to lag developmentally in their capacity to decenter, a key to empathy. As a continued reflection of their diminished empathy, children with ADHD seemed to lack insight into the importance of reciprocity; thus the play frame was often disrupted. Their impaired play illuminates the essence of the social problems children with ADHD experience in their developmental course.Less empathetic responding in children with ADHD has been proposed previously by Barkley (1997 ) in his model of constructing a unifying theory for ADHD. Barkley (1994 ) supposed that people with ADHD would be less responsive to the needs, feelings, and opinions of others (i.e., be less empathetic), stemming from a reduced ability to interpret events from others' viewpoints that was the result of poor inhibitory control. Braaten and Rosen ( 2000 ) subsequently supported this hypothesis. However, their study did not measure empathy as an observable behavior, but rather inferred this from how children with ADHD reported they felt about other children. Furthermore, the small sample size limited generalization of the findings.Lack of empathetic responding has also been reported in studies conducted on both oppositional defiant disorder and conduct disorder (American Psychiatric Association, 2000 ; Cohen &Strayer, 1996 ). Being less empathetic may have significant implications for prosocial development, particularly because play is the milieu within which children develop social skills and form peer relationships. Both Barkley (1997 ) and Hartup (1996 ) emphasized the importance of empathy for prosocial behavior, and it is known that many children with ADHD continue to have serious social difficulties throughout adolescence and adulthood (Barkley, 2006a ; Schachar, 1991 ; Wood, 1995 ).We did not set out to examine empathetic response in children with ADHD. Although social concomitants of ADHD are well documented, the finding that social difficulties seem to reflect lower levels of empathy was unexpected. Furthermore, we consider that these findings may, in fact, underestimate the degree of the problem. Children with severely disruptive behavior and more complex presentations of ADHD were likely to have been excluded from the study, both as a function of the strict adherence to exclusion criteria and the fact that participation in the study was voluntary. Thus, it is less likely that children with complex presentation and needs participated in the study. If more children with ADHD with complex presentations had been included, the phenomena of lack of empathetic response might have been even more pronounced. Further research clearly is necessary.LimitationsIt was not feasible to draw a random sample. Hence, the ability to generalize the results of this study to children with ADHD in other populations is somewhat limited. However, the strength of the results indicates the need for further research.Conclusions and ImplicationsOur interpretation of the constellation of scores led us to suggest that the play of children with ADHD is characterized by lower levels of empathetic responding. Clearly, further research is needed to replicate the findings. Lower social skills and less empathy can have adverse implications for the development of morality and can potentially lead to anti-social behavior. The results suggest that consideration should be given to the process of decentering when planning interventions for children with ADHD.。