As described above, an important step forward would be to consider more ecologically valid and easily generalizable delivery mechanisms for these types of interventions. Diamond et al.’s (Diamond et al., 2007
) work sets the scene for this as their intervention was integrated into the everyday school program. While this is an ideal platform for intervention, it is unlikely to be possible to have all school programs adapted; and even if it were, it would be very difficult for teachers to individualize the program to children’s specific needs. Therefore the field would be well-served by trying to design ecologically valid home-based interventions to complement what is available to date.
One way to do this would be to administer the intervention in the form of “play” (ranging from quiet play to that involving physical exercise) within the family. Most studies examining the role of play in development have focused on its role in the development of social skills and interpersonal development. As children move from early “parallel play” into social interactive play, they learn to “read” others’ intentions, take turns, regulate their emotions and behavior, and engage in the give-and-take of interpersonal relations. It is within this social context that many of the higher-order executive functions, that may be uniquely human, are most likely to develop and flourish (Diamond et al., 2007
; Luria, 1966
; Vygotsky, 1978
). Although research is limited, juvenile play has been posited to play a role in facilitating neural development. Similar to the effects physical exercise on brain functioning in humans (Gold et al. 2003
; Ferris, Williams & Shen, 2007
; Rasmussen et al. 2009
; Seifert et al. 2010
; Strohle et al. 2010
; Tang et al. 2008
; Zoladz et al. 2008
), Gordon, Burke, Akil, Watson, & Panksepp (2003)
reported that play increases BDNF, a key modulator of neuronal development and plasticity, in the amygdala and dorsolateral PFC of juvenile rats. Similarly, juvenile play in rats stimulates c-Fos gene expression in a number of brain areas (Gordon, Kollack-Walker, Akil, & Panksepp, 2002
). Finally, “chronic play therapy” reduced right frontal lesion-induced hyperactivity in juvenile rats, and enhanced access to rough-and-tumble play in normal animals improved performance on indices of behavioral inhibition (Panksepp, Burgdorf, Turner, & Gordon, 2003
). Based on these and similar findings, Panksepp and colleagues (Panksepp, 2007
; Panksepp et al., 2003
) have speculated that the impulsive and hyperactive behaviors characteristic of ADHD may reflect overactive playful urges in some children and that enhanced access to play may have therapeutic benefits. However, data supporting or refuting this speculation are sparse.
Thus the creative use of directed play, which incorporates cognitive challenges and physical exercise, may have the potential to serve as a vehicle for treatment of children with ADHD. In particular, the intrinsic rewarding qualities of play (i.e., it’s fun) makes it an ideal delivery system for treatment of children with ADHD, who are known to be highly responsive to continuously rewarding contingencies; yet highly resistant to more effortful and less rewarding (i.e., less fun) tasks. In addition, physically and cognitively demanding play within a social context can be used to mold and develop social skills and, when structured in the appropriate manner, can potentially enhance cognitive and behavioral development, and neural growth. Importantly, we do not propose that this approach to intervention would necessarily target or remediate the core neural pathology that causes ADHD. Rather, it would facilitate development and growth of a wide array of cortical regions and their associated functions, which in turn, would allow for the implementation of compensatory mechanisms that have the potential to improve functioning in individuals with the disorder.
There are numerous common children’s games, activities and exercises that would be easy for families to play together and involve the use of wide ranging brain areas, targeting the diffuse neurocognitive deficits that have been associated with ADHD. For example, the game “S]imon-says” involves inhibitory control, “my grandmother went to the market” involves working memory, and “hopscotch” involves physical exercise and requires motor control. We hypothesize that an intervention that focuses on encouraging parents to play these games in a structured and incremental manner with their children, and encouraging children to play these games with siblings and friends, on a daily basis, if complied with, would have an impact on both neural development and behavioral regulation. As compared to other more effortful and less palatable interventions, compliance may be less of a problem with such an intervention. Also, unlike other neurocognitive training programs that continue for a fixed period of time, at which point training ends, in this case, the goal would be for the wide ranging play activities to continue long after the termination of the active intervention. While in the short-term it is unlikely that such an intervention would generate effect sizes comparable to medications, the goal is to impact the long-term trajectory of the disorder. As such, extended follow-up periods will be required to make comparisons to well-validated treatments (i.e., stimulant medication; behavior modification).
In addition, beyond directed play and exercises with parents, it is possible that engaging children in sports, nature (Kuo & Taylor, 2004
), and other group-based cognitively and physically challenging activities may provide an avenue for neural and cognitive growth that would serve to facilitate the diminution of ADHD severity across development. Such activities could be provided in schools (Diamond et al., 2007
), after school programs, or in summer camps, although it would be important that the activities continue over an extended period of time.
Although many questions remain regarding the clinical utility these cognitive and exercise-related interventions for children with ADHD, there are several clear directions for future work in this area that, ultimately, will allow us to determine the usefulness of this treatment modality within the context of well-established interventions for children with ADHD.