Manual 21391458

Manual 21391458
The impact of a board game as parent
guidance strategy to reinforce Cognitive
Control Therapy in the home environment
Hestie Sophia Byles
2007
The impact of a board game as parent guidance
strategy to reinforce Cognitive Control Therapy
in the home environment
by
Hestie Sophia Byles
Submitted in partial fulfillment of the requirements for the degree
MAGISTER EDUCATIONIS
(Educational Psychology)
in the
Faculty of Education
Department of Educational Psychology
University of Pretoria
SUPERVISOR:
Dr. Suzanne Bester
CO-SUPERVISOR:
Prof. Irma Eloff
PRETORIA
April 2007
… it’s like trying to build a house of cards in a dust storm.
You have to build a structure to protect yourself from the wind
before you can even start on the cards
(Hallowell 1992:1).
Dedicated to Henry,
my structure when I have to build in a storm!!!
ACKNOWLEDGEMENTS
On every unknown road travelled, there are beacons of light guiding the way. The road I
took when starting on this dissertation was no different and it is with a warm heart that I
salute the following beacons:
Dr Bester, thank you for being an inspiration (in more than just the academic arena)
and for never accepting good as good enough. Thank you and for your caring support
through it all. You made me believe that what I did was worth doing!
Prof. Eloff, thank you for all the smiling faces, colourful stickers and words of
encouragement accompanying your feedback. It made me smile when I felt like crying.
Thank you for your invaluable input which made a huge contribution to the quality of my
work.
To Mary and her mother, thank you for inviting me into your home and working with me
to create something that may benefit many others in the same situation as you, you
were amazing!
Prof de Boer, for your generosity and guidance – you made it so much easier!
To my parents who made all this possible. Thank you for believing in me and for giving
me the opportunity to reach my potential. My sincere thanks to you (my in-laws and my
wonderful family) for enduring my constant complaining, for always being willing to
listen and give advice and above all for loving me so much that it gave me the courage
to fly!
To my Heavenly Father – my Rock, my Source, my Stronghold in times of trouble –
Thank you for giving me the strength and the guidance to run this race to the end and
for never leaving nor forsaking me.
To my amazing husband, Henry, you are my world and my reason. You never gave up
on me and you never expected anything but the best. Your support and guidance, your
care and rational thinking mean more than I can ever put into words.
forever!!
---oOo---
I love you
DECLARATION
I, Hestie Sophia Byles (student number 20021781), hereby declare that all the resources that
were consulted are included in my reference list and that this study titled: The impact of a
board game as parent guidance strategy to reinforce Cognitive Control Therapy in the
home environment, is my original work.
______________________
HS Byles
April 2007
SUMMARY
THE IMPACT OF A BOARD GAME AS PARENT GUIDANCE STRATEGY TO REINFORCE
COGNITIVE CONTROL THERAPY IN THE HOME ENVIRONMENT
by
Hestie Sophia Byles
Supervisor
:
Dr. Suzanne Bester
Co-Supervisor:
Prof. Irma Eloff
Department
:
Educational Psychology
Degree
:
MEd (Educational Psychology)
In this study the impact of a board game as parent guidance strategy to reinforce Cognitive
Control Therapy (CCT) in the home environment of a child with ADHD was explored. The
influence of such a board game, based on the principles of CCT, on multiple contexts of the
child’s existence - therapeutic and family contexts - was also investigated. There were two
reasons for involving the parents in therapy. Firstly, children with an attention problem are
situated within contexts and the effect of ADHD can permeate to the home and school
environments. Secondly, for Cognitive Control Therapy (CCT) to be successful, it needs to
be sustained by frequent repetition. It was hypothesized that sustainability of the effect of
CCT should rise substantially after introduction of the board game, as the child and the
parent can reinforce the principles of CCT by using it, even without being able to attend a
session. The board game was designed by using the principles for game development as
articulated by Dodge.
A case study was then conducted by using a mixed methods approach, where quantitative
and qualitative data were obtained.
Data collection strategies consisted of quantitative
methods in the form of the Cognitive Control battery (pre and post test), and the Copeland
Symptoms checklist.
Qualitative strategies included parental feedback, qualitative data
during therapy sessions (observations and therapeutic notes) and a semi-structured
interview with the mother. Data was collected before, after and during the intervention. The
intervention consisted of individual therapy with the participant, parent guidance and parallel
implementation of the designed board game by the parents with the child-participant. The
quantitative data (from the CCB and the Copeland Symptoms Checklist) from the post test
indicated that sensitivity towards distractions remains a concern, and that parental
implementation of a board game (incorporating elements of CCT) with a child can possibly
have a slightly negative effect on cognitive control functioning. However, the scope of this
case study does not allow direct correlations to be drawn between the parental input and the
child’s cognitive control functioning. It does point to the possibility of heeding caution when
implementing a board game to reinforce CCT principles by a parent.
Conversely, the
findings from the study also indicated that family relations improved. Five qualitative insights
emerged: i) increased ability to distinguish between relevant versus irrelevant information in
the participant; ii) increase in organizational thought in the therapeutic situation and at home;
iii) improved communication between parent and child, resulting in improved skills to
maintain discipline; iv) improved interaction among family members; and v) transfer of skills
to the mother. The study found that the greatest contribution of the board game appears to
be the improvement experienced in the family context – probably as a result of increased
interaction among family members and attention focused on the problem.
Key words:
•
Board game
•
Parent guidance strategy
•
Cognitive Control Therapy
•
Home environment
•
Attention Deficit Hyperactivity Disorder
•
Games in therapy
•
Middle childhood phase
•
Systems theory
•
Game design and development
•
Intervention
---oOo---
—i—
TABLE OF CONTENTS
Page
CHAPTER 1
ORIENTATION, PROBLEM STATEMENT AND DEFINING OF CONCEPTS
1.1
INTRODUCTION
1
1.2
STATEMENT OF PURPOSE
2
1.3
PROBLEM STATEMENT
2
1.3.1
PRIMARY PROBLEM STATEMENT
2
1.3.2
CRITICAL QUESTIONS
3
1.4
DEFINING KEY CONCEPTS
3
1.4.1
BOARD GAME
3
1.4.2
PARENT GUIDANCE STRATEGY
3
1.4.3
COGNITIVE CONTROL THERAPY (CCT)
3
1.4.4
HOME ENVIRONMENT
4
1.4.5
RELATED CONCEPTS
4
1.4.5.1
1.4.5.2
1.4.5.3
4
5
6
Attention Deficit Hyperactivity Disorder (ADHD)
Games in therapy
Middle childhood phase
1.5
CONCEPTUAL FRAMEWORK OF THE STUDY
7
1.5.1
SANTOSTEFANO’S THEORY ON COGNITIVE CONTROL THERAPY
7
1.5.1.1
1.5.1.2
1.5.1.3
1.5.1.4
1.5.1.5
7
8
8
8
8
1.5.2
Body-ego-tempo regulation
Focal attention
Field Articulation
Levelling-sharpening
Equivalence range
SYSTEMS THEORY
12
— ii —
Page
1.6
RESEARCH METHODOLOGY AND STRATEGY
12
1.6.1
PARADIGM: INTERPRETIVIST
12
1.6.2
RESEARCH DESIGN
13
1.6.3
SAMPLING
15
1.6.4
DATA COLLECTION
16
1.6.5
DATA ANALYSIS
16
1.6.6
ETHICAL CONSIDERATIONS
17
1.6.7
ROLE OF THE RESEARCHER
18
1.6.8
LIMITATIONS OF THE STUDY
18
1.6.9
POTENTIAL CONTRIBUTIONS OF THE STUDY
18
1.7
PROGRAM OF THE STUDY
19
---oOo---
— iii —
Page
CHAPTER 2
LITERATURE REVIEW: ADHD, THE DIAGNOSIS, THE EFFECT ON THE
FAMILY AND INTERVENTION
2.1
OVERVIEW OF THE CHAPTER
21
2.2
INTRODUCTION
21
2.2.1
DIAGNOSTIC DESCRIPTION OF ADHD
22
2.2.2
ADHD: A SYSTEMIC PROBLEM AND ITS IMPLICATIONS
25
2.2.2.1
2.2.2.2
26
28
The effect on parent(s)
The effect on siblings
2.2.3
THE EFFECT ON THE CLASSROOM ENVIRONMENT
29
2.3
INTEGRATING THE SYSTEMS
30
2.4
CHILDREN WITH ADHD AND ASSESSMENT
32
2.4.1
THE COPELAND SYMPTOMS CHECKLIST
34
2.4.2
AN INTRODUCTION TO THE CCB
34
2.5
ADHD AND INTERVENTION
36
2.5.1
COGNITIVE CONTROL THERAPY (CCT)
37
2.5.1.1
2.5.1.2
37
37
What is Cognitive Control Therapy
CCT relevant to the study – “Find the shapes”
2.6
PARENTAL INVOLVEMENT IN AND BEYOND THERAPY
39
2.6.1
PARENT GUIDANCE
39
2.6.2
GAMES IN THERAPY
41
2.6.3
THE ROLE OF PARENTS WITH REGARD TO THE BOARD GAME
42
2.7
CONCEPTUAL FRAMEWORK
44
2.8
CONCLUSION
46
---oOo---
— iv —
Page
CHAPTER 3
THE DESIGN AND USE OF A BOARD GAME IN CCT THERAPY
3.1
INTRODUCTION
47
3.2
DEVELOPMENT OF THE BOARD GAME
47
3.3
THE DESIGN OF A BOARD GAME
48
3.3.1
CONTENT ANALYSIS
48
3.3.2
INCUBATION
50
3.3.3
CHUNKING
50
3.3.4
ALIGNING
53
3.3.5
DRAFTING
54
3.3.6
INCUBATION
54
3.4
CONTENTS OF THE BOARD GAME
56
3.4.1
THE BOARD
56
3.4.2
THREE DECKS OF CARDS
57
3.4.3
SHAPES
58
3.4.4
PAWN
58
3.4.5
DICE
58
3.4.6
PLAYERS
59
3.6
RULES OF THE BOARD GAME
59
3.6.1
THE BOARD
59
3.6.2
THE CIRCLES AROUND THE EDGES OF THE BOARD
60
3.6.3
DESCRIPTION OF THE CARDS
60
3.6.3.1
3.6.3.2
3.6.3.3
60
61
62
Bunny cards
Bear cards
Butterfly cards
3.7
ALTERNATIVE WAYS TO PLAY THE GAME
64
3.8
CRITICAL REFLECTION
64
3.9
CONCLUSION
64
---oOo---
—v—
Page
CHAPTER 4
DISCUSSION OF THE RESEARCH PROCESS
4.1
INTRODUCTION
65
4.2
RESEARCH PROCESS
65
4.2.1
NOTES ON THE QUALITATIVE DATA COLLECTION
65
4.2.2
DATA ANALYSIS
67
4.3
DISCUSSION OF THE CASE STUDY
68
4.3.1
BACKGROUND OF THE PARTICIPANTS
68
4.4
DISCUSSION OF RESULTS
68
4.4.1
QUANTITATIVE RESULTS
68
4.4.1.1
4.4.1.2
68
72
4.4.2
QUALITATIVE INSIGHTS
76
4.4.2.1
4.4.2.2
76
78
4.4.2.3
4.4.2.4
4.4.2.5
4.5
CCB - FDT
Copeland Symptoms Checklist
Ability to distinguish between relevant versus irrelevant information
Increase in organizational thought in the therapeutic situation
and at home
Improved communication resulting in improved skills to maintain
discipline
Improved interaction among family members
Transfer of skills to the mother
CONCLUSION: INTEGRATING QUANTITATIVE AND QUALITATIVE
RESULT
---oOo---
80
82
83
84
— vi —
Page
CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS
5.1
INTRODUCTION
86
5.2
SUMMARY OF THE RESULTS WITH REFERENCE TO RELEVANT
LITERATURE
86
5.3
CONCLUSIONS GLEANED FROM THE STUDY
88
5.4
ADDRESSING THE RESEARCH QUESTIONS
89
5.4.1
PRIMARY RESEARCH QUESTION
89
5.4.2
CRITICAL QUESTIONS
90
5.5
ADDRESSING THE ASSUMPTIONS
91
5.6
LIMITATIONS OF THE STUDY
93
5.7
CONTRIBUTIONS OF THE STUDY
94
5.8
RECOMMENDATIONS
95
5.8.1
FURTHER RESEARCH
95
5.8.2
EDUCATIONAL PSYCHOLOGY PRACTICE
95
5.9
CONCLUSION
95
---oOo---
LIST OF REFERENCES
97
---oOo---
— vii —
LIST OF APPENDICES
Page
APPENDIX A:
Copeland Symptoms Checklist
103
APPENDIX B:
Supporting documents
105
APPENDIX C:
Field notes of significant CCT Sessions and interactions with
the parents
107
APPENDIX D:
Interview with the mother
117
APPENDIX E:
Permission to do research
124
APPENDIX F:
Informed consent
125
APPENDIX G:
Ethical clearance
127
---oOo---
LIST OF FIGURES
Page
FIGURE 1.1:
Graphic representation of the Systems Theory
12
FIGURE 2.1:
The reciprocal influence of the systems on one another
31
FIGURE 2.2:
The conceptual framework
45
FIGURE 3.1:
A photograph of the draft prototype of the board game
56
FIGURE 3.2:
A graphic representation of the board
57
FIGURE 3.3:
A graphic representation of the shapes used in the board game
58
FIGURE 3.4:
A graphic representation of the back of the Bunny cards
61
FIGURE 3.5:
A graphic representation of the back of the Bear cards
62
FIGURE 3.6:
A graphic representation of the back of the Butterfly cards
63
FIGURE 3.7:
An example of the shapes found on the Butterfly cards
63
— viii —
LIST OF TABLES
Page
TABLE 1.1:
Interpretivist paradigm
13
TABLE 2.1:
DSM-IV-TR Diagnostic Criteria for Attention-Deficit/Hyperactivity
Disorder
23
TABLE 2.2:
The steps of the programme “Find the shapes”
38
TABLE 3.1:
Chunking
51
TABLE 3.2:
Alignment between the game (cards) and content (CCT)
53
TABLE 4.1:
Scores from the Copeland Symptoms Checklist for the pre test and
post test completed by Mary’s mother
72
TABLE 4.2:
Scores from the Copeland Symptoms Checklist (pre test) completed
by Mary’s teacher
74
---oOo---
LIST OF GRAPHS
Page
GRAPH 4.1:
Mary’s profile for the CCB pre test
69
GRAPH 4.2:
Mary’s profile for the CCB post test
70
GRAPH 4.3:
A graphic representation of the scores where the mother
experienced the greatest improvement based on the results
of the Copeland Symptoms Checklist
73
---oooOooo---
CHAPTER 1
ORIENTATION, PROBLEM STATEMENT
AND DEFINING OF CONCEPTS
1.1
INTRODUCTION
The purpose of my research is to explore the impact of a board game as a parent guidance
strategy to reinforce Cognitive Control Therapy1 in multiple contexts of a child’s life with
Attention Deficit Hyperactivity Disorder2 (such as the therapeutic as well as the family
context). The board game, based on the principles of CCT, will be used to involve parents of
children displaying symptoms of Attention Deficit Hyperactivity Disorder (ADHD)3 in the
therapeutic process.
The statistics relating to children who display symptoms of ADHD indicates that
approximately 3-5 percent of primary school learners are affected by this disorder (Dennison,
1990:307; Salend & Rohena, 2003:2). So, in a primary school with six grade 1 classes
approximately six grade 1 learners could be affected by symptoms associated with ADHD,
and 6-12 parents and six teachers are faced with the task of assisting these children to adapt
in a school environment.
With these statistics in mind, it becomes increasingly important for the primary caregivers4
involved in the child’s life to be active participants in the intervention, aimed at addressing the
difficulties associated with ADHD.
According to Green (1997:39), parental support and
involvement (as well as the standard of parenting) are interwoven in the treatment of ADHD
(Green, 1997:38-39).
Supporting children to manage attention problems is a complex issue – no simplistic answer
exists.
It would appear that the most successful approach in dealing with an attention
problem currently consists of a multi-disciplinary approach, including a combination of
medication, behaviour intervention and sometimes skills training for parents.
1
2
3
4
This study
Hereafter referred to as CCT. CCT is a form of therapy used for children experiencing difficulties to
selectively withhold attention. See chapter 2 section 2.4.1.
The term Attention Deficit Hyperactivity Disorder will be used to refer to children with the cluster of behaviour
patterns commonly exhibited by children with this condition and is not intended to classify, diagnose, or
discriminate against a child in any way.
Attention Deficit Hyperactivity Disorder will hereafter be referred to as ADHD. The symptoms of ADHD will
be discussed in chapter 2 section 2.2.1.
For the purpose of this study primary caregivers will refer mainly to the parents (legal guardians) with whom
the child lives but can also include members of the child’s extended family.
—1—
focuses on CCT as a behaviour intervention strategy. CCT is a therapeutic intervention
technique involving a structured programme designed specifically to target attention
problems (Santostefano, 1995:5). The main purpose of this study is to explore whether the
principles of CCT applied in the therapeutic situation, could be reinforced through the use of
a structured, fun board game5 in the home environment.
Parents will act as a support
system by using a board game to reinforce the principles applied during the therapeutic
sessions.
Children suffering from an attention problem do not suffer in isolation, so ADHD can be
regarded as a systemic problem6. The effect of this disorder permeates multiple facets of the
child’s life, therefore an intervention that targets the home environment has the potential to
form an integral part of the ADHD treatment plan. In this study the parents of a child with
ADHD will be regarded as the most significant individuals in the child’s system.
The
researcher acknowledges at this point that members of the child’s extended family could also
be regarded as significant others and might well be included in the implementation of the
game in the family context.
STATEMENT OF PURPOSE
1.2
The purpose of the proposed study is to explore the impact of a board game as a parent
guidance strategy to reinforce CCT in the child’s home environment.
1.3
PROBLEM STATEMENT
1.3.1
PRIMARY PROBLEM STATEMENT
How can a board game be used as a parent guidance strategy to reinforce CCT in a child’s
home environment?
1.3.2
CRITICAL QUESTIONS
ª
How can the constructs of CCT be accommodated in a board game for children in
the middle school phase?
ª
How can parents reinforce CCT in the home environment by using a board game?
ª
What effect does parental involvement have on the CCT process?
5
6
Compare chapter 3.
ADHD as a systemic problem will be discussed in section 1.5.2 of this chapter based on the Systems theory
and again in chapter 2 section 2.2.2.
—2—
1.4
DEFINING KEY CONCEPTS
1.4.1
BOARD GAME
A board game7 can be defined as a structured game with specific rules of interaction
(Bellinson, 2002:2). In this study the term will refer to a game played by two players on a
specific board providing all the elements needed to play the game, based on the principles of
the CCT programme: “Find the shapes”8 (Santostefano, 1995:128-129).
1.4.2
PARENT GUIDANCE STRATEGY
According to Du Toit (1994:64) parent guidance can be regarded as the provision of
conscious guidance to parents in order to assist them with the complicated task of raising
their child. In this study a parent guidance strategy can be seen as any tool used to
facilitate parent guidance, and will take on the form of facilitation by the therapist rather
than conscious guiding. However, the aim remains to enable the parent to be better
equipped for the task of parenting a child with ADHD. Parental involvement in the therapeutic
process will be accomplished by implementing a parent guidance strategy – in this case a
board game. Parent guidance in this context aims to:
ª
Communicate the principles of CCT to the parent in a “hands-on” and practical way.
The parents are given the opportunity to experience it first-hand while playing the
board game with their children.
ª
Teach parents through experience and active involvement in a collaborative and cooperative process, rather than by means of a therapist giving advice or passing
knowledge to the parent.
This collaborative and co-operative process could result in parents playing an important role
in CCT therapy and becoming part of the collaborative team in which parents will act as cotherapists in reinforcing CCT by means of a board game (Kendall & Choudhury, 2003:93).
1.4.3
COGNITIVE CONTROL THERAPY (CCT)
CCT is a playful therapeutic approach designed to address cognitive dysfunctions that can
contribute to a child experiencing difficulties in school (Santostefano, 1995:1). CCT as a
therapeutic intervention consists of the following programmes: (1a) Who is me? Where is
7
8
See chapter 3 for a detailed discussion on the development of this board game.
“Find the shapes will be discussed in chapter 2 section 2.4.1.2.
—3—
me? (1b) Moving fast and slow, (2a) Follow me, (2b) Which is big? Which is small? (3) Find
the shapes, (4) Remember me, (5) Where does it belong? (Santostefano, 1995:51). Each of
these programmes aims to rehabilitate the dysfunctional cognitive structures preventing a
child from functioning in a well-adapted manner, as well as from performing at school
(Santostefano, 1995:1).
For the purpose of this study CCT will refer to therapy with field articulation cognitive control,
programme 3: find the shapes (Santostefano, 1995:128-129). According to Santostefano
(1995:128) field articulation cognitive control defines the manner in which a child scans,
articulates, and responds to a field of information in terms of what is relevant and irrelevant
for the task at hand (Santostefano, 1995:128).
The central focus of this study is on the principles of CCT (which the board game will aim to
reinforce), as well as the people who will work towards the reinforcement, namely the
parents.
1.4.4
HOME ENVIRONMENT
The home environment can be seen as a physical space or a place where a family lives. It is
however also experienced emotionally in a particular way and implies an underlying
togetherness (Pretorius, 1998:56). In this study the home environment will refer to the
permanent residence of the child with symptoms of ADHD and her parents (this could also
include significant others living with the family or visiting).
1.4.5
RELATED CONCEPTS
1.4.5.1 Attention Deficit Hyperactivity Disorder (ADHD)9
When attempting to define ADHD, the most logical place to start, in the researchers’ opinion,
should be the classification system (Diagnostic and Statistical Manual fourth version [DSM IV
– TR]) used by psychologists and other practitioners in the process of diagnosing a child with
ADHD. According to the DSM IV (American Psychiatric Association, 2000:85), ADHD is
classified according to five criteria10:
ª
Criterion A can be seen as an unrelenting or constant pattern of inattention and/or
hyperactivity-impulsivity that occurs more frequently and is more severe than
9
10
ADHD will be discussed in more detail in chapter 2 section 2.2.1.
Compare chapter 2, table 2.1 for DSM IV-TR criteria for ADHD.
—4—
expected of someone at a particular developmental level (American Psychiatric
Association, 2000:85).
ª
The appearance of some hyperactive-impulsive or inattentive symptoms which
cause impairment, should have an onset before age 7 and makes up Criterion B.
The Inattentive symptoms are however often only diagnosed at a later stage
(American Psychiatric Association 2000:85).
ª
Criterion C represents the presence of impairment in at least two areas of the child’s
life, for example family life and the school environment (American Psychiatric
Association, 2000:85).
ª
To meet Criterion D, impairment in the developmentally appropriate social and
academic functioning of the child should be evident (American Psychiatric
Association, 2000:85).
ª
Finally, Criterion E states that ADHD does “not occur exclusively during the course
of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder.
It should not be better accounted for by another mental disorder (e.g., a Mood
Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder)
(American Psychiatric Association, 2000:85).
In other words, ADHD can be seen as a disorder that can cause a child to appear incapable
of paying attention or as ‘always on the go’; much too active and impulsive; or a combination
of the afore-mentioned. For the purpose of this study the focus will be on one of the subtypes
of ADHD, which has to do with the inability to withhold attention selectively from irrelevant
stimuli (ADHD Predominantly Inattentive Type). This inability should be inappropriate to the
developmental level of the child and should have serious implications for academic
achievement (Wenar & Kerig, 2000:120).
In other words, the definition of ADHD for this study will be a problem in sustaining
attention to a task due to the child’s inability to withhold attention selectively from
irrelevant stimuli.
1.4.5.2 Games in therapy
Games appear to have existed for as long as mankind has. Archaeological studies and
excavations have led to the discovery of many ancient and prehistoric games. In those early
years, it would appear as if games had a lot to do with adaptation and survival, as the games
demanded physical strength and agility (Schaefer & Reid, 2001:3). In the context of this
study, adaptation and survival have less to do with physical strength. Yet, adaptation is still
vital for human existence. In this study a child with ADHD needs to adapt and survive in a
—5—
family environment, social settings and in the classroom situation, something that could
prove to be very challenging at times.
The premise this study is based on is that the “survival” of the child with ADHD may thus be
assisted through an intervention strategy making use of their most natural instinct: playing.
Children with ADHD are not unable to pay attention: they simply pay attention to a task that
they enjoy and at the same time find it hard to withhold attention selectively from what they
perceive to be more enjoyable tasks (Sears & Thompson, 1998:4). It is envisaged that
games, and in this instance a board game, could be enjoyable to children, thus captivating
their attention, while at the same time engaging them in a survival course by reinforcing the
principles of CCT.
The types of games that can be used in therapy are numerous. Some of the well-known
methods of play therapy are puppets, storytelling, bibliotherapy, finger painting, music
therapy, sand play, ball play and board games (Kaduson & Schaefer, 2003:159-271;
Schaefer & Cangelosi, 2002:161-311). As mentioned in section 1.1, this study will explore
the impact of using a board game to reinforce the principles of CCT.
1.4.5.3 Middle childhood phase
The child who will be participating in the study will be selected from the middle childhood
phase, which refers to the life stage from age six to twelve, and is characterised by
significant cognitive, social, emotional and self-concept development (Louw, Van Ede &
Louw, 1999:326).
Intervention during the middle childhood phase, aimed at balanced
development could ease or enhance later development (Louw et al 1999:326). The chances
of the board game having a long-term positive effect on especially cognitive functioning may
therefore increase drastically if its use commences in the middle childhood phase. As far as
social, emotional and peer development is concerned, children in this phase of life are too
old to play or act out as required in play therapy and yet too young to verbalise like an
adolescent would (Bellinson, 2002:3). They are primarily at the shrugging, silent, “Fine,”
“Nothing” stage of communication. They do play board games though (Bellinson, 2002:3).
For this reason it is envisaged that a board game could appeal to children in the middle
childhood phase.
—6—
1.5
CONCEPTUAL FRAMEWORK OF THE STUDY
1.5.1
SANTOSTEFANO’S THEORY ON COGNITIVE CONTROL THERAPY
This research is informed by Santostefano’s theory on cognitive control as a possible
intervention technique for children with an attention problem (Santostefano, 1995:8).
Santostefano developed this form of therapy because he was of the opinion that children
who have an attention deficit of some nature, cannot be effectively treated by engaging them
in therapy that requires them to explore their inner thoughts, fantasies and emotions. The
theory also states that engagement through play therapy will not be effective, as the
cognitive structures required for these very procedures, are dysfunctional and remain
unmodified after completion of the therapy (Santostefano, 1995:4-5).
The question can be raised why the research intends utilizing a board game, which is
regarded as a form of play therapy. At this juncture it is important to point out that the board
game developed in this research is structured, concrete, and not based on any form of
fantasy or imaginative play, but rather on the concrete principles of CCT.
Thus, in the
researcher’s opinion, it does not tap into dysfunctional cognitive structures as conceptualised
in CCT theory (Santostefano, 1995:4-5). Furthermore, the board game will be based on the
principles of CCT - and the goal of CCT is to rehabilitate particular dysfunctional cognitive
structures that seem to contribute to attention problems – so that children with attention
problems are enabled to cope with the requirements of reality and fantasy, as well as to
apply appropriate affect and behaviour in their everyday lives (Santostefano, 1995:4-5).
As mentioned earlier, effective learning can only take place if the child’s cognitive structures
are functional (Santostefano, 1995:12). Five cognitive controls involved in the process of
effective learning form part of Santostefano’s theory and are now discussed briefly:
1.5.1.1 Body-ego-tempo regulation
This process of cognitive control involves the manner in which the body and body motility are
represented and regulated through the use of images or symbols. The ability to differentiate
between different perceptions and representations of the body (for example walking slowly
like a snail, versus walking fast like a cheetah) becomes more differentiated with age
(Santostefano, 1995:13). Young children will move at more or less the same speed in both
the above instances, but this will become more refined as they mature. Such cognitive
control needs to be in place in order for children to learn to direct their attention and register
body sensations and movements appropriately (Santostefano, 1995:84).
—7—
1.5.1.2 Focal attention
This relates to the manner in which a field of information is surveyed or scanned. It can be
done in an active or passive fashion, or covering a narrow or wider area (Santostefano,
1995:13). Therapy with focal attention aims to help children keep their head oriented forward
while following the target only with their eyes (Santostefano, 1995:112).
1.5.1.3 Field articulation
“Field articulation” refers to the way in which a person reacts when faced with stimuli that are
either relevant or irrelevant to the task at hand. At first attention is directed to both relevant
and irrelevant information, but as children mature it becomes easier to withhold attention
selectively from irrelevant stimuli, while only directing attention to information relevant to a
specific task (Santostefano, 1995:13). The implications of this programme are that it may
contribute to a child being better equipped to distinguish between relevant versus irrelevant
information (Santostefano, 1995:133).
1.5.1.4 Levelling-sharpening
This cognitive control concerns the manner in which images are differentiated so as to
enable a person to notice subtle differences when comparing past information to present
information (Santostefano, 1995:13). The levelling-sharpening programme aims to improve
the size and length of memory (Santostefano, 1995:148).
1.5.1.5 Equivalence range
This cognitive control concerns the grouping and categorizing of information. Grouping is
initially based upon a few narrow and concrete categories (in young children), but gradually
expands to broader categories based on more abstract concepts (older children) and/or
incorporates functional characteristics for grouping purposes.
The afore-mentioned cognitive controls are interdependent in the sense that they form a
hierarchy, whereas the higher cognitive controls rely on the effective functioning of lower
cognitive controls for effective functioning (Santostefano, 1995:15). Based on the five
cognitive controls and the hierarchy in which they are found, a rehabilitation plan (for
dysfunctional cognitive structures) was developed. This plan consists of different
programmes and also follows a hierarchy where the first programme employs the least
complex cognitive controls, whereas the final programme requires the most complex
—8—
cognitive controls (Santostefano, 1995:50-53). The programmes of which the rehabilitation
plan consists are discussed next, based on the research done by Santostefano (1995:85191); Engelbrecht (1996:203-204) and Eloff (1997:192-197).
•
Programme 1A: Body ego-tempo regulation – Who is me? Where is me?
The tasks in the programme aim to make children aware of their bodily sensations and
movements, so that their capacity to perceive and describe these are developed. They then
need to represent these sensations and movements by making use of gestures in a symbolic
way. Representations will be made in the form of static positions (for instance standing),
dynamic positions (for instance crawling) and through static and dynamic relations to other
objects (for instance wearing various clothing).
In the process they will learn that their
gestures express meaning and are interpreted by others accordingly.
•
Programme 1B: Body ego-tempo regulation – Moving fast and slow
In this programme the focus is on varying body tempos executed in either large or small
settings, and understanding that different tempos convey different meanings to others.
Examples of tasks are: using the entire body in an unrestricted space and using only the
hand and arm to move a pencil in a small space.
•
Programme 2A: Focal attention – Follow me
The purpose of the tasks is to direct and sustain attention on moving objects. Experiences
offered will promote the development of the capacity to use passive scanning efficiently
during the process of symbolic functioning. Tasks progress from where children track neutral
concrete objects by walking alongside them, to tracking the same object while sitting down,
keeping the head still and tracking only with the eyes. The same progressive process is then
followed with objects that become increasingly symbolic.
•
Programme 2B: Focal attention – Which is big? Which is small?
The goal of this programme is to engage the child in active and systematic scanning of
information. Experiences are offered that promote the development of the capacity to use
active scanning efficiently during the process of symbolic functioning. Children will perform
tasks where comparing two sets of information varying in only one or two dimensions is
required, for example the objects of information will first be located close to one another and
will gradually be moved further apart. Later, complexity is also increased by introducing
more dimensions of variance in the objects presented.
—9—
•
Programme 3: Field articulation cognitive control – Find the shapes11
This programme contains more complex cognitive activities and requires that the child has
already mastered Body-ego-tempo cognitive control as well as “Focal attention” cognitive
control. It addresses children’s ability to selectively focus their attention on concrete (“as is”)
information, as well as on information transformed by means of symbols and fantasies in the
process of symbolic functioning. This information is initially characterised as relevant, but
irrelevant information is added as the tasks become progressively more complex.
•
Programme 4: Levelling-Sharpening - Remember me?
The purpose of this programme is to develop the ability to construct progressively more
complex fields of information. The child is expected to handle external information as it is, as
well as information transformed by means of the process of symbolic functioning.
The
construction of the information must be kept stable and must be related to present
perceptions.
The tasks are based on the principle that the therapist creates a field of
information; shows it to the child; then covers it; then alters it. The therapist then uncovers
the field of information, asks the child to identify the change (if any), and finally to restore it to
its previous construction. The fields of information created by the therapist become
increasingly complex as therapy progresses.
•
Programme 5: Equivalence range - Where does it belong?
Programme 5 aims to develop the ability to categorise information that is “narrow and broad,
concrete and abstract, and to learn the utility of these concepts” (Santostefano, 1995:170).
The therapist introduces an object to the child who then categorizes the object in terms of its
physical or functional characteristics. Next, other objects with the same characteristics are
grouped together with the above-mentioned object; then the groups or categories are
evaluated. After this the groups are broken up and the objects are used to form new and
different groups, based on different characteristics.
The theory of CCT (specifically programme 3: “Field articulation cognitive control – find the
shapes”) will form the basis of the study, as the board game will be based on these
principles. Through the use of the board game the study aims to reinforce new, functional
cognitive structures, which can be facilitated by the use of CCT.
1.5.2
SYSTEMS THEORY
The importance of parental involvement and the emphasis placed on the family system in
this study makes it imperative to include systems theory. Systems theory states that each
11
The steps of this programme can be found in chapter 2 section 2.4.1.2, table 2.2.
— 10 —
system contains its own parts, regulated by boundaries. These boundaries define which
parts belong to the system. There are reciprocal relationships among the parts of a particular
system – whatever happens to one part of the system influences other parts present in that
same system (Thomas, 2000:537-538).
Bronfenbrenner is considered to be the father of the systems theory and according to his
model a distinction needs to be made between Micro, Meso, Exo, Macro and Chrono
systems existing in the child’s life (Adelman & Taylor, 2002:51-53).
ª
Micro system: This includes the systems that the child is directly involved with on a
day-to-day basis and where daily activities occur, for example the family and the
school systems (Adelman & Taylor, 2002:51-53).
ª
Meso system: On this level the micro systems interact with one another, resulting in
influences or events occurring in one system, having an influence on the other
systems (Adelman & Taylor, 2002:51-53).
ª
Exo systems: The child is not directly involved in these systems but the systems
have an influence on, or are influenced by people in the micro systems. Examples
are a parent’s place of work, a siblings’ peer group or a local community
organisation (Adelman & Taylor, 2002:51-53).
ª
Macro systems: This includes the dominant social structures, values and beliefs
that have an influence on or are influenced by all other levels of systems (Adelman
& Taylor, 2002:51-53).
ª
Chrono systems: Developmental reciprocity of systems is at play here, where a
particular system is always in a state of development. This has an influence on
other systems and on the child, who is also at a particular developmental stage.
Because of the many different levels of systems encompassed by this model, a graphic
representation follows on page 12.
Systems theory could serve to support the presupposition that positive effects experienced in
one part of the system, could at some time have a positive impact on other parts of the
system. The different parts of the system, as mentioned earlier, could include areas relating
to the home environment – such as parenting, discipline, and relationships between different
family members – as well as school related issues – such as attitudes in the classroom and
school performance.
— 11 —
FIGURE 1.1:
GRAPHIC REPRESENTATION OF THE SYSTEMS THEORY
MACRO
MESO
Micro 1: e.g.
Family
EXO
e.g.
Dad’s
work
Micro 2:
e.g. School
Micro 3:
e.g. Peers
CHRONO
1.6
RESEARCH METHODOLOGY AND STRATEGY
1.6.1
PARADIGM: INTERPRETIVIST
In this study the interpretivist paradigm is used. This approach places an emphasis on
understanding the meaning assigned to people’s own experiences (Schwandt, 2000:191;
Jansen, 2004:380). The experiences relevant to this study are those of parents of children
with ADHD.
The focus will be on understanding the meanings they assign to their
experience of the process of implementing the board game. To ensure that the participants’
meanings are truly their own and can be regarded as trustworthy, they will be allowed to
have access to interpreted interviews, in order to confirm the construction of meaning
contained in it. Furthermore, open-ended questions will be used when conducting semistructured interviews, thereby ensuring that the participants give their own meaning and are
not being led by the questions.
— 12 —
TABLE 1.1:
INTERPRETIVIST PARADIGM
PARADIGM
Interpretivist
ONTOLOGY
EPISTEMOLOGY
Reality can be
understood and
interpreted but not
predicted or controlled.
Knowledge arises from
observation and
interpretation.
REPORT12
Description of day-today events
experienced in the
field, or description of
feelings.
Taken from De Vos (1998:246)
The interpretivist paradigm was chosen for this particular study because it is the researcher’s
opinion that one can only really explore the effect of the implementation of the board game in
the home environment by interpreting the experience of the family who uses it. Knowledge
on this subject can only be obtained through observation and interpretation of the process of
implementation (See table 1.1).
1.6.2
RESEARCH DESIGN
A case study will be used as research design because case studies are known to clearly
illustrate a particular phenomenon. A case study could offer the opportunity to work closely
with the family as a whole, assessing the process of implementation of the board game, as
well as the impact, if any, that it had on the broader family system and on the
school/classroom environment.
It could provide the researcher with the opportunity of
examining to what extent the board game allows for reinforcement of the principles of CCT.
This type of design explains by example how the phenomenon appeared. It is thus easier to
relate to and to understand (Cohen, Manion & Morrison, 2000:181). The use of a case study
also invites the use of different types of (qualitative and quantitative) data (Denscombe,
2003:31).
The research will be done using a mixed methods approach, which is a combination of
qualitative and quantitative approaches in a single study (Maxwell & Loomis, 2003:241). It is
the researcher’s opinion that neither a qualitative nor a quantitative approach alone would
yield sufficient information on the proposed topic, as a quantitative approach would not yield
the emotional aspects of the implementation of the board game in the home environment.
On the other hand, a pure qualitative study would not allow the researcher the opportunity to
compare results in order to determine the impact of the board game. The advantages of
both approaches combined will establish the best-suited approach for this particular study.
12
The aspects referred to under the column “report” will be discussed in the sections that follow.
— 13 —
Quantitative data will be collected using two sources. The first would be the quantitative data
obtained from the Cognitive Control Battery (CCB) – Fruit Distraction subtest. The results
from the CCB - FDT indicate a tendency in a child for attention problems and also whether a
child’s attention problem is the result of an inability to withhold attention selectively from
external stimuli – like movements, noises or objects in the child’s environment – or whether it
is due to an inability to withhold attention selectively from internal stimuli – like the child’s
own thoughts, feelings and fantasies – or both. Based on the scores of the CCB - FDT an
individual profile of attention deficit emerges. This data will be used as pre and post tests in
order to determine if any improvement in the individual profile of the child (and consequently
her ability to selectively withhold attention from irrelevant information) is evident when
comparing the results of her profile before commencement of the therapeutic process and
again after termination thereof.
The second set of quantitative data will be gathered from the Copeland Symptoms
Checklist13, which will be completed by parents and teachers and used as pre and post tests.
This checklist needs to be completed by both parties as the criteria for ADHD state that the
symptoms need to be present in more than one context of the child’s life.
Verschuren (2003:128) refers to the use of case studies in a quantitative approach as risky
because participants are usually tested at one particular time, when they are not in their own
environment and when outside forces that have an impact on the subject are not in play.
When reference is made to symptoms of ADHD, as is the case in this study, many of the
“outside forces” impacting on the child (external and internal stimuli) are present in any
situation. Secondly, in this study, two different sets of quantitative data will be used: profiles
from the CCB, and the Copeland Symptoms Checklist, together with several sources of
qualitative data.
More than one method of data collection will be used for purposes of
triangulation. The advantages of triangulation are that it limits researcher bias, as similar
findings from different methods lend a greater credibility to research (Cohen et al 2000:112).
Apart from the use of different data sources, the process of collecting data will follow the
therapeutic process over a period of time. This will decrease the effect of obtaining data that
reflects performance on one specific day only.
Another way in which this issue will be addressed is that data will be collected in a qualitative
approach by interpreting a semi-structured interview and feedback from the parents, based
on their observations regarding the process and progress of the child while using the board
game. This data will be collected mainly from the parents of the child-participant and will
13
The Copeland Symptoms checklist is a parent and teacher questionnaire aimed at determining ADHD
symptoms which are presented by a child in a certain context be it at home of at school.
— 14 —
therefore be from the child’s own environment. The researcher’s own observations of the
child in every therapy session and records of her progress will also form an important part of
the qualitative data in monitoring the reinforcement of CCT.
The standardised measures will thus be used firstly as a means whereby a suitable case
study for this research can be selected. The findings obtained by these measures will then
be used to determine the findings of the study, in conjunction with the meanings assigned by
the various role players, as well as observations and reports on the progress and the process
of the implementation of the board game.
1.6.3
SAMPLING
Using a case study enables the researcher to make use of purposeful sampling, which allows
the selection of cases rich in the types of information needed for the intended research
(Patton, 2002:230).
The purposeful sampling strategy used in the research is criterion
sampling (Patton, 2002:243), which enables the researcher to select a research participant
who shows symptoms of ADHD with special reference to inattentiveness.
Criterion sampling will be utilised: a child in the middle childhood phase, who experiences
difficulties in withholding attention selectively, and her mother14, will be selected at the
Training Facility of the University of Pretoria15. The suitability of the participants will be
determined by an assessment done by a Master’s student, using the Copeland Symptoms
Checklist (completed by the parent(s) and the teacher), as well as the CCB - FDT. The most
important criteria that need to be met are problems in sustaining attention to the task at hand
due to difficulties in selectively withholding attention from irrelevant information.
After the assessment the child will be referred to the researcher. This type of sampling can
be seen as convenience sampling in that it will be “built upon selections which suit the
convenience of the researcher and which are first to hand” (Denscombe, 2003:16).
The child selected will attend formal CCT sessions with the therapist twice weekly at the
Training Facility at the University of Pretoria’s Department of Educational Psychology.
During the rest of the week her mother will use the board game at home to reinforce those
principles dealt with in the session. Frequency of use of the board game during the week will
14
15
Even though it was the intention that both parents be involved in the study, it was evident from the start that
the mother would be the one who would play the game with her child, and give feedback to the researcher.
This training facility offers psychological services, performed by Honnours and Masters degree students in
Educational Psychology, as part of their clinical training, under the supervision of registered Educational
Psychologists.
— 15 —
be determined by the commitment and schedule of the parents. Ideally the game should be
played on all the days when no therapy sessions take place.
1.6.4
DATA COLLECTION
Data will be collected by means of:
ª
Quantitative data from the Fruit Distraction Test on the Cognitive Control Battery
before therapy commences and after it is terminated.
ª
Quantitative data from the Copeland Symptoms Checklist before therapy
commences and after it is terminated.
ª
Qualitative interpretation of the feedback from the parents on the progress and
process of the use of the board game.
ª
Qualitative data obtained from the therapeutic situation through observation.
ª
Qualitative data received from the child in the form of her comments during
therapeutic sessions, as well as data from the school in the form of feedback from
teachers and/or academic reports.
ª
Qualitative data derived from a semi-structured interview with the mother on her
experience and feelings about the implementation of the board game in their home
environment.
1.6.5
DATA ANALYSIS
The results as obtained from the Fruit Distraction Test on the Cognitive Control Battery will
be scored and interpreted according to the instructions and norms set out in the CCB Manual
by Sebastiano Santostefano (1998). The scoring instructions and criteria for interpreting the
Copeland Symptoms Checklist16 are included in the checklist.
The semi-structured interview will be recorded on audiotape. The contents of the interview
will be described after the researcher has searched for meaning assigned by the parents,
and having categorizing these. Finally, qualitative insights crystallising from these categories
will be identified (Cohen et al 2000:282; De Vos, 1998:337).
Qualitative data obtained from the therapeutic situation will be documented through a
process of observation and note-taking (or field notes). The use of observational notes will
give detailed accounts of what happened in the sessions, who said what and when it
occurred. There is little interpretation involved in observational notes. A second type of note16
The Copeland Symptoms Checklist can be found in Appendix A.
— 16 —
taking – theoretical notes – will form part of the therapeutic sessions, serving to interpret,
identify patterns and explain the events noted (De Vos, 1998:285-286).
Qualitative data received from the child as well as the school will be recorded and used as a
means to evaluate any progress made during the therapeutic process. Progress made by
the child in each session will be noted in the observations and combined with other
qualitative data to determine the influence the board game has had on the reinforcement of
the therapeutic process.
1.6.6
ETHICAL CONSIDERATIONS
In this study the following ethical considerations will be adhered to:
ª
Informed consent will be obtained from the parents of the child involved.
ª
The researcher will be honest towards the research participants with regard to the
outcome of the quantitative measures as well as the progress (if any) made in
therapy.
ª
In order to safeguard the participants from any kind of harm, be it physical or
psychological (emotional), the researcher must be aware of the feelings and
sensitivities surrounding families with children who are challenged by attention
problems.
ª
Absolute confidentiality will be maintained with regard to the participant’s personal
information, especially when in communication with the school and teachers.
ª
Extreme caution will be applied in order to limit the misinterpretation of data, by
maintaining open communication with all participants and making notes available for
them to read and by ensuring that they were understood correctly.
ª
The research results will be communicated to the participants (McMillan &
Schumacher, 2001:196-198).
ª
The intervention with the child-participant will continue until satisfactory progress is
displayed – even though the study is completed.
ª
Permission from the Head of Department Educational Psychology of the University
of Pretoria will be obtained to select a client from their training facility and then to
use the training facility’s premises to conduct the therapy.
ª
Ethical clearance will be obtained from the Ethics Committee of the University of
Pretoria prior to commencing the research.
ª
The researcher will adhere to the guidelines as set out by the Health Professions
Council of South Africa regarding the regulation of the activities of an Intern
Educational Psychologist in conducting research. In this regard all professional acts
— 17 —
will be performed under supervision of a registered psychologist and will be limited
to acts directly related to the topic under investigation, as contained in this research.
1.6.7
ROLE OF THE RESEARCHER
In this study the role of the researcher will be that of:
ª
A therapist, working together with the child and her mother.
ª
A facilitator of parent guidance with regard to the use of the board game.
ª
Empowering the mother with knowledge regarding issues relating to ADHD.
ª
An observer of behaviour as well as of the progress of therapy.
ª
A developer or designer in the process of creating the board game.
1.6.8
LIMITATIONS OF THE STUDY
Due to the fact that data will be gathered from a single case study, the research findings will
not be generalisable, as the sample used in this case is not representative of the total
population of children who have a problem sustaining attention on the task at hand. It is
however not the aim of this research to generalize the findings to the general population, but
rather to examine the possibility of (a) reinforcing the principles of CCT, (b) using the board
game as a method for reinforcement of therapeutic content and (c) determining whether any
of the principles permeate to other areas of the participants’ lives.
To be in a position to explore the possibility of reinforcing CCT by using a board game, it is of
great importance that the board game be properly implemented at home. The researcher,
however, is not in a position to ensure that this will happen and has to rely on the
commitment and co-operation of the mother as well as on her feedback.
Finally the researcher needs to be sensitive towards the possibility of researcher bias
especially with regards to the fact that the researcher is passionate about this game. In an
attempt to limit researcher bias, the researcher will have supervisory discussions addressing
any issues that may emerge as the research progress and during the interpretation of all
data. The researcher will also aim to establish a certain degree of objectivity by having a
reflection session after every therapeutic session.
1.6.9
POTENTIAL CONTRIBUTIONS OF THE STUDY
It is envisaged that the introduction of the game will enhance the outcomes of CCT and that it
may lead to children progressing faster in the therapeutic process. The improved
— 18 —
performance of the child with an attention problem in CCT may also bring about an
improvement in academic performance in general. The effects of the board game may also
flow through to other areas of the child’s life, for example family relationships and discipline.
Apart from the possible positive effect on the different systems in the child’s life, the
introduction of the board game in the home environment may lead to parent empowerment
and education. It could be anticipated that through the use of the board game as a parent
guidance strategy, therapists and families will unite and work together in the process of
managing attention problems.
The study of the effects of this board game will constitute a new knowledge base, as CCT
has never before been studied in the context of reinforcement through a board game. The
interpretation of individual experiences regarding the implementation of the board game
could enhance its development and shed light on the applicability of the game as an
intervention strategy. This applied research could offer therapists and parents additional
resources and unite them in their attempts to assist children with attention deficits.
1.7
PROGRAMME OF THE STUDY
CHAPTER 1: INTRODUCTION AND ORIENTATION
Chapter one introduces the reader to the study and states the purpose of the study, research
questions, rationale for the study and the research design.
CHAPTER 2: LITERATURE REVIEW
Chapter two represents a literature study, which reflects the conceptual framework for the
research. This will cover aspects relating to:
ª
Attention Deficit Disorder: A description of ADHD and its impact on the family
(parents and siblings) as well as in the classroom environment.
ª
Assessment of ADHD with particular reference to the Copeland Symptoms Checklist
and the CCB.
ª
Cognitive Control Therapy as intervention for ADHD.
ª
Parent guidance as well as the role of the parent in and beyond therapy.
ª
Games in the therapeutic environment.
The conceptual framework – containing all the assumptions that underlie the study – will also
be discussed in this chapter.
— 19 —
CHAPTER 3: THE DESIGN AND DEVELOPMENT OF THE BOARD GAME
Chapter three will consist of a description of the development and design of the board game.
Aspects covered in this chapter will include the methodology underlying the development and
design process as well as the content and the rules of the board game.
CHAPTER 4: DISCUSSION OF THE RESEARCH PROCESS
In this chapter the research process that will be utilized to study how a board game can be
used as a parent guidance strategy to reinforce CCT in the home environment of the child
with ADHD, will be discussed. This will be followed by a description of the quantitative data
and findings and the qualitative insights which emerged.
Finally an integration of both
qualitative and quantitative data will be offered.
CHAPTER
5:
SYNOPSIS
OF
FINDINGS,
LITERATURE
CONTROL,
CONCLUSIONS
AND
RECOMMENDATIONS
This final chapter will contain a discussion of the findings in relation to the relevant literature.
Based on these findings, research questions will be answered and assumptions (stated in
chapter two) tested. This will be followed by conclusions as well as recommendations for the
future.
---oOo---
— 20 —
CHAPTER 2
LITERATURE REVIEW: ADHD, THE DIAGNOSIS, THE
EFFECT ON THE SYSTEMS, ASSESSMENT AND INTERVENTION
2.1
OVERVIEW OF THE CHAPTER
In this chapter a description and definition of ADHD in relation to the specific context of this
study is provided. Reference is made to the history of ADHD and the impact of ADHD on the
family system as well as the classroom situation. A brief overview of assessment is given,
with special reference to the CCB as indicative of the appropriate CCT programme that
should be selected.
Thereafter the focus shifts to CCT as intervention strategy.
A
description of the CCT programme find the shapes, on which the board game is based, is
given. Finally parent guidance, as well as the role of the parent in and beyond therapy, is
discussed. The aim of this chapter is to share the unique position of the child with ADHD, to
highlight the challenges the families and teachers of these children are faced with and to
introduce the different intervention possibilities.
2.2
INTRODUCTION
So what’s it like to have ADD17? … It’s like driving in the rain with bad windshield
wipers. Everything is smudged and blurred and you’re speeding along, and it’s
reeeeally frustrating not being able to see very well. Or it’s like listening to a radio
station with a lot of static and you have to strain to hear what’s going on. Or it’s like
trying to build a house of cards in a dust storm. You have to build a structure to
protect yourself from the wind before you can even start on the cards
(Hallowell, 1992:1).
Some of the earliest writings on ADHD can be traced back to 1845 when Dr Heinrich
Hoffman, a physician, wrote a children’s book called “Der Struwwelpeter” (Mash & Barkley,
1996:64; Wikipedia, 2006:12). One of the stories found in this book entitled “Die Geschichte
vom Zappel-Phillipp” is about a boy named “Fidgety Phillip” (Godwin-Jones, 1994-1999).
This little boy is a very good example of what is known today as a child with ADHD.
17
Some literature sources use the term ADD when referring to ADHD. The term ADD will be used in quotations
but reference in the text will still be made to ADHD.
— 21 —
The period of 1917-1919 brought about more serious mentioning of ADHD. Many children
suffered symptoms of ADHD after their brains were affected by the encephalitis epidemic that
threatened the people of that time. As a result, what is known today as ADHD was then
called Minimal Brain Damage and Brain-Injured Child Syndrome (Mash & Barkley, 1996:6465). After observations were done in 1966, researchers discovered that the symptoms (of
ADHD) occurred even without any pathology or injury to the brain and the condition was
subsequently renamed Minimal Brain Dysfunction (Mash & Barkley, 1996:64-65; Wikipedia,
2006:12).
In the 1970’s the term Hyperkinetic Disorder was used when referring to ADHD
(Chaimberlain & Sahakian, 2006:36). A decade later the name was again changed, and
appeared in the DSM-III, as Attention Deficit Disorder (ADD) for the first time. Soon after this,
in the revised edition of the DSM-III the term was changed to Undifferentiated Attention
Deficit Disorder. Then in 1994, with the release of the DSM-IV-TR, the term Attention Deficit
Hyperactivity Disorder was introduced and is still used today (American Psychiatric
Association, 2000:85; Wikipedia, 2006:12).
Even though professionals have struggled for decades to arrive at a suitable classification
and terminology, the disorder we all know as ADHD has been with us for a while. It would
appear that through all this time, scientists have regarded the classification of the disorder as
important and the researcher agrees that classification has its role to play in the treatment of
ADHD. In this study in particular it serves as common ground between the therapist and the
parents. Once parents understand what symptoms encompass ADHD, they may feel more in
control of what needs to be done to help their child. Being aware of the classification of
ADHD could also lead to parents being more tolerant and understanding of their children’s
symptoms. However, irrespective of the term used to classify ADHD and the presumed
understanding which accompanies it, ADHD has a profound impact on those who live with it
every day.
2.2.1
DIAGNOSTIC DSCRIPTION OF ADHD
In chapter 1 it became clear that children with ADHD experience a whole range of
behaviours.
The most distinguishing characteristic, however, is a developmentally
inappropriate persistent pattern of inattention and/or hyperactivity-impulsivity (American
Psychiatric Association, 2000:85). ADHD is often used as an umbrella term and distinguishes
between three subtypes. The first subtype is called Attention Deficit/ Hyperactivity Disorder,
Combined Type. This subtype is diagnosed if six (or more) symptoms of inattention and six
(or more) symptoms of hyperactivity-impulsivity have persisted for at least six months. Most
— 22 —
children and adolescents with the disorder are being diagnosed with this type (American
Psychiatric Association, 2000:87).
The second subtype is Attention Deficit/Hyperactivity Disorder, Predominantly Inattentive
Type18. This subtype is diagnosed when six (or more) symptoms of inattention (but fewer
than six symptoms of hyperactivity-impulsivity) have persisted for at least six months.
Hyperactivity may still be a significant clinical feature in many such cases, whereas other
cases are purely inattentive (American Psychiatric Association, 2000:87).
Finally, Attention Deficit Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type is
characterized by six (or more) symptoms of hyperactivity-impulsivity (but fewer than six
symptoms of inattention), which have persisted for at least six months. Inattention may often
still be a significant clinical feature in such cases (American Psychiatric Association,
2000:87).
In order to confirm the presence of ADHD and to distinguish the afore-mentioned subtypes,
classification in terms of the five categories19 contained in the DSM-IV-TR needs to take
place.
The criteria for ADHD are outlined in table 2.1 and indicate the combination of
symptoms that should be present to make a diagnosis of ADHD.
TABLE 2.1:
DSM-IV-TR DIAGNOSTIC CRITERIA FOR ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
A.
Either (1) or (2)
(1)
six (or more) of the following symptoms of inattention have persisted for at least six months to a degree
that is maladaptive and inconsistent with developmental level:
Inattention
(a)
often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities.
(b)
often has difficulty sustaining attention in tasks or play activities.
(c)
often does not seem to listen when spoken to directly.
(d)
often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace (not due to oppositional behaviour or failure to understand instructions).
(e)
often has difficulty organizing tasks and activities.
(f)
often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as
schoolwork or homework).
(g)
often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or
tools).
(h)
is often easily distracted by extraneous stimuli.
18
19
ADHD Predominantly Inattentive Type will be the focus of this study. The aim of using this disorder is
however not to discriminate in any way. These symptoms, as indicated by an assessment with the CCB and
the Copeland Symptoms Checklist, are used solely as a guide for the selection of a research participant and
for explaining a phenomenon.
Compare chapter 1 section 1.4.5.1.
— 23 —
(i)
is often forgetful in daily activities.
(2)
six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least six
months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a)
often fidgets with hands or feet or squirms in seat.
(b)
often leaves seat in classroom or in other situations in which remaining seated is expected.
(c)
often runs about or climbs excessively in situations in which it is inappropriate (in adolescence or adults,
may be limited to subjective feelings of restlessness).
(d)
often has difficulty playing or engaging in leisure activities quietly.
(e)
is often “on the go” or often acts as if “driven by a motor”.
(f)
often talks excessively.
Impulsivity
(g)
often blurts out answers before questions have been completed.
(h)
often has difficulty awaiting turn.
(i)
often interrupts or intrudes on others (e.g., butts into conversations or games).
B.
Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age
seven years.
C.
Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at
home).
D.
There must be clear evidence of clinically significant impairment in social, academic, or occupational
functioning.
E.
The symptoms do not occur exclusively during the course of a pervasive developmental disorder,
schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder
(e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).
Code based on types
314.01 Attention-deficit/hyperactivity disorder, combined type: if both Criteria A1 and A2 are met for the
past six months.
314.00 Attention-deficit/hyperactivity disorder, predominantly inattentive type: if Criterion A1 is met but
Criterion A2 is not met for the past six months.
314.01 Attention-deficit/hyperactivity disorder, predominantly hyperactive-impulsive type: if Criterion A2
is met but Criterion A1 is not met for the past six months.
Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no longer
meet full criteria, “in partial remission” should be specified.
(American Psychiatric Association, 2000:92-93).
Based on the introduction of this chapter it is evident that ADHD has been in existence for
many years, during which time the term has undergone many conceptual changes. Today,
even with a widely acknowledged term and three subtypes included in the classification
system, it would appear that ADHD cannot be seen exclusively as a “problem in paying
attention” or “being hyperactive”. It involves all systems that are linked to it in the sense that
parents and teachers need to pay extra attention to children with ADHD to ensure that they
finish tasks, follow through on instructions, organize their environment and have the correct
“tools for the task” at their disposal. Children with ADHD need to be reminded to adhere to
social rules in classrooms and at other social events and their interaction with others needs to
be monitored and facilitated throughout.
— 24 —
This study will focus on ADHD predominantly inattentive type. Children with this type of
ADHD are often “undiagnosed” until the age of 10 because they cause no behaviour
problems in the classroom (Sears & Thompson, 1998:4,14; Green, 1997:6). They do not
direct their attention selectively in class and consequently do not follow the teacher,
frequently resulting in academic underachievement. This often causes frustration for the
child, the parents and the teacher (Sears & Thompson, 1998:4,14; Green, 1997:6).
The afore-mentioned behaviour can be ascribed to the neurological component of the
disorder.
It hinders the child when processing information and making the most of
educational experiences (Voeller, 2004:798). As a result there is several areas where the
child will typically experience difficulties, including learning, peer relationships, self-esteem,
mood, behaviour, and family relations (Voeller, 2004:798). These difficulties will be discussed
in more detail in the next section with reference to its implications for the two most important
areas of the child’s functioning, namely the family and the school.
2.2.2
ADHD: A SYSTEMIC PROBLEM AND ITS IMPLICATIONS
This section will focus on the micro systems20 relevant to the child’s life. These are the
systems that have the most significant influence on the child and in turn are influenced the
most by the child. As mentioned in chapter 1, these systems all have a reciprocal effect on
each other. In this section the child’s influence on the parents, the siblings, and the school
and vice versa, is discussed.
One opinion about ADHD that many may agree with is that children with ADHD are difficult to
raise (Sears & Thompson, 1998:3). They have a particular cluster of temperament traits that
characterize them (Sears & Thompson, 1998:3). The implications of ADHD are however not
only limited to the family environment and when engaging with a child who suffers from
ADHD, the impact this disorder has on every area of the child’s life cannot be ignored. The
two main areas where the implications of ADHD are most visible are probably the family and
the school environment.
The impact of ADHD on families is far-reaching. A number of studies (Power, Russell, Soffer,
Blom-Hoffman, & Grim, 2002:119; Johnston & Mash, 2001:193; Podolski & Nigg, 2001:511)
have illustrated how parents’ stress levels are influenced when they have a child with an
attention disorder. Findings from these studies indicate that families and children who are
affected by ADHD have to cope with increased levels of stress and their relationships are
characterised by greater conflict. The behaviour of both parents and children seem to be
20
Compare chapter 1 section 1.5.2.
— 25 —
negative and controlling.
It furthermore emerged from these studies that mothers, in
particular, often felt incompetent as parents. Contributing to the stress are tiredness,
confusion and self-doubt (Green, 1997:74).
Apart from parental stress as a direct result of the impact of ADHD, parents may also have
consulted with various professionals and endured ample assessments and tests before
finding out what is “wrong” with their child. They are probably also bombarded with people
ascribing their child’s behaviour to bad parenting (Green, 1997:74). Interventions with families
thus often accommodate stress factors and focus on “friendly” activities that alleviate and
diffuse rather than exacerbate accumulated stress. This study aligns itself with this approach
by using a game that will involve the family in the therapeutic process (a structured playbased activity). The game is intended for the family to enjoy with the child who receives
intervention for ADHD. The assumption could be that a game may provide a constructive
format for conducting an intervention with a family (with a child with ADHD) while the
complexities underlying the dynamics of a child with ADHD in a family is not negated.
Parents play a prominent role in managing ADHD. In most cases they are the primary
caregivers of the child and spend a lot of time with the child. They often have a significant
influence on different levels of the child’s development and a meaningful discussion of ADHD
should thus also include an understanding of the effect ADHD has on parents.
2.2.2.1 The effect on parent(s)
The child with ADHD is part of a system, which is involved in, and affected by the
manifestation of ADHD. Becky Milton (2001:1) tells the story of herself and her child who has
been diagnosed with ADHD. She expresses her dismay at the school for blaming her for her
son’s “behaviour problems” and regrets listening to the “professionals” at school who
continually told her to punish her child. “I began to realize that my son was slipping away from
me and my family“ (Milton, 2001:1).
The so-called “behaviour problems” of children with ADHD can often be traced back to a
neurological origin. Neuropsychologists have found that children with ADHD have a
weakness in the frontal lobe of their brains (Green, 1997:18). The frontal lobe is responsible
for executive functions namely motivation, attention and sequencing of actions (Sadock &
Sadock, 2003:84).
Impairment in this area would thus result in a child being unable to
conform to the expectations for good behaviour – i.e. to sit still, to concentrate, to exert
control over their own impulses, to obey, to co-operate, to share, to play and to interact
appropriately – and as a result are often seen as defiant. Once a child is labelled as defiant,
— 26 —
the pressure on the parent increases.
They are probably already disheartened by their
child’s behaviour at home and in addition they may have to deal with complaints from
teachers as well (Barkley, 2000:92).
According to Wenar and Kerig (2000:122) mothers respond in a more negative and less
rewarding way towards their children with ADHD. The authors also report an increase in
conflict between father and child, although to a lesser extent than in the mother-child
relationship. It would, however, appear that the negativity improves once treatment reduces
the symptoms of ADHD (Wenar & Kerig, 2000:122). The possibility exists that the negative
reactions and increased conflict between parents and children often stem from parents being
uninformed with regard to ADHD. They may not know why their child acts in a certain way
and therefore wrongly interpret the behaviour as non-compliant or even defiant.
Lack of knowledge and understanding of their child with ADHD could lead to parents losing
confidence in their own ability to raise their impossible-to-manage-child, as Green (1997:5)
indicates, often becoming increasingly punitive. The fact that children with ADHD always
want more love and attention exacerbate this situation. Even though parents spend more
time with their child with ADHD, they often seem to be in disagreement (Simmons & York,
2006:2; Sears & Thompson, 1998:161). This may be ascribed to the fact that children with
ADHD are not emotionally and socially mature (in accordance with their age) and as a result
they do not show the necessary understanding and common sense that is expected of them
(Green, 1997:6). The researcher can relate to the findings and acknowledge the fact that this
characteristic may complicate the task of parents who want their children to receive all the
love they need.
The possibility that all these variables may lead to guilt-ridden parents
comes to the fore. It is the researcher’s opinion that these underlying feelings constitute a
significant part of the total impact of ADHD on those confronted with it. Probably one area
where the influence of these feelings of guilt can become most visible is when parents may
start to believe that they could in some way be responsible for their child’s ‘unacceptable’
behaviour. Some parents may even feel anger and resentment towards parenting as a whole
or even towards their child (Simmons & York, 2006:2; Green, 1997:75).
Tynan (2005:2) acknowledges the fact that raising a child with ADHD is not without
challenges. He notes that educating and informing parents as well as introducing support
groups, may help parents adapt to their circumstances (Tynan, 2005:2). It is envisaged that
the introduction of a board game in the family system will fulfil the roles of educating, and
supporting children with ADHD as well as their families. The role of the researcher will not be
to educate, but rather to facilitate the process of understanding ADHD and to support the
child with ADHD. To achieve this, it will not only be vital to involve parents in the process of
— 27 —
therapy but, even more importantly, to gain their co-operation – especially in light of the
previous paragraph where the emotional load that ADHD places on parents became evident.
The researcher will need to be particularly sensitive towards the emotions of the mother; the
possibility that she may feel reluctant to engage in therapy (for various reasons, e.g. fear of
failure, complicating parent-child relationships, time pressures etc.) should be acknowledged
and kept in mind throughout. Working with parents and their children with ADHD require
much understanding, sensitivity and empathy on the part of the researcher.
However, not all characteristics or symptoms associated with ADHD are negative. Many
great men who had a substantial impact on the world, such as Thomas Edison, Winston
Churchill and Wolfgang Amadeus Mozart, are reported to have had ADHD (Sears &
Thompson, 1998:3). All these influential men used their ‘disorder’ to their own advantage
and, instead of being labelled as distractible, impulsive or hyperactive, their qualities are
called creativity, energy, spontaneity and ability to focus intently (Sears & Thompson,
1998:3). Thus in spite of the vast negative impact of ADHD, parents can also focus on the
positive aspects of ADHD if they know what these are and how to bring them out in their
child. Parents may become aware of the positive traits through spending focused time with
their child. The time and attention bestowed on the child with ADHD often become part of the
challenge the siblings are faced with. The various challenges will now be discussed.
2.2.2.2 The effect on siblings
In a house where one child has ADHD life will not be free from challenges for the siblings.
Children with ADHD often react impulsively and emotionally, thereby possibly exposing their
siblings to uncomfortable confrontational situations (Green, 1997:77; Sears & Thompson,
1994:17). The siblings may feel that they are being treated unfairly and may from time to
time be blamed for something their sibling with ADHD did (Simmons & York, 2006:2; Green,
1997:77). Children with ADHD often exhibit great difficulties in delaying gratification. As a
result they may be inclined to invade the space of siblings at times that appear to be
inappropriate – especially when they are studying for exams or when they invite a friend over
to visit (Simmons & York, 2006:2; Green, 1997:78-79; Sears & Thompson, 1994:20).
When a child with ADHD and their siblings are in the same school, this also poses its own
unique challenges. Apart from the normal issues that a child has to cope with in a class
situation, these siblings are often faced with additional challenges in the form of remarks
made about their brother’s or sister’s behaviour. The child is not in a position to do anything
about the sibling’s behaviour and may experience such statements as very hurtful (Green,
1997:78).
— 28 —
Having a child with ADHD in the house often not only poses challenges for the child, the
parents and the siblings individually, but also as systems connected to each other. They
form micro systems that have a profound influence on each other and affect the atmosphere
in the house. The home is however, not the only place where challenges need to be faced
and adjustments are required. The classroom situation is another environment where the
symptoms of ADHD make coping very difficult.
2.2.3
THE EFFECT ON THE CLASSROOM ENVIRONMENT
The classroom is usually where attention problems are detected (Chaimberlain & Sahakian,
2006:35). As soon as a child with ADHD enters the classroom, the teacher becomes a
prominent role player in the process of identification of learning difficulties, which are often
associated with children with ADHD (Sears & Thompson, 1998:172). If teachers are informed
about ADHD, they could assist the parents to take the first step on the road to intervention.
When teachers are empowered it helps them to realise that when a child with ADHD enters
the classroom their impulsive and “loud” behaviour in class is not intentional or aimed at
hindering the teaching and the learning process. Of equal importance is the fact that children
with ADHD – Predominantly Inattentive Type – often do not show overt behaviour and
therefore don’t draw attention to themselves, causing them to often go unnoticed (Lerner,
2000:540; Picton, 1999:1). In cases like these it seems meaningful if teachers were made
aware of the symptoms associated with ADHD as well as the different subtypes that can
occur.
In the school environment, challenges often relate to the poor organisational skills of most
children with ADHD. This may lead to their neglecting to bring the correct equipment and/or
books to school; not being able to organise their desks; achieving poor academic results
(especially in mathematics); and struggling with comprehension of tasks and commands
(Picton, 1999:1).
Teachers who were asked to identify those behavioural and emotional difficulties of children
with ADHD that are most severe and prevalent in their view, reported, among others, work
avoidance, lack of concentration and difficulties in cooperating (Poulou & Norwich, 2000:183).
The behaviours viewed as occurring most frequently were lack of concentration, talking
without permission, untidiness and fidgeting (Poulou & Norwich, 2000:184).
Lack of
concentration was again mentioned when the teachers reported the most severe behaviours
(Poulou & Norwich, 2000:184). These behaviours often interfere in the teaching process and
— 29 —
it is clear that especially a lack of concentration amongst learners is of great concern to
teachers.
Another aspect intertwined with school life is that of socializing with peers. The symptoms
accompanying ADHD, such as hyperactivity, impulsivity and/or inattentiveness, may make it
difficult for children with ADHD to establish friendships. Even if they do manage to make
friends, the symptoms may complicate maintaining these friendships. They are often
regarded as unpopular among their class members (Lerner, 2000:235-236).
It is evident from the preceding discussion that the symptoms of ADHD have an impact on
each individual who has relations with the child with ADHD. Systems however are not only
influenced individually, but they also influence each other reciprocally. The effect of the
child’s behaviour in one system may very well extend into some or all of the other systems.
In the next section the (negative) influence of ADHD is illustrated by a graphic representation
of the above discussion. It is however a decontectualized representation and in order to
understand the views of this study it should be compared with the conceptual framework
discussed in section 2.6.
2.3
INTEGRATING THE SYSTEMS
In chapter 1 reference was made to Bronfenbrenners’ model of systems theory. The focus at
this point should be placed on the meso system i.e. the system where all systems interact
with one another. From the previous section it can be concluded that stressors may be
present in each system as a result of ADHD but, in interaction, the meso systems may also
have a reciprocal effect on stress levels within the overall system.
Figure 2.1 (see p.31) indicates some of the stress factors present in the different systems:
•
Family
As mentioned earlier, families (especially parents) feel tired and stressed and experience
feelings of anger and resentment.
•
Peers
Relationships between children with ADHD and their peers are often compromised, due to
certain symptoms of ADHD – such as impulsivity in social settings, impulsive telling of lies,
intense emotional reactions or overreacting and difficulties in delaying gratification (Sears &
Thompson, 1998:20-31). The occurrence of these symptoms in social settings may cause
others to perceive the child with ADHD in a negative light, resulting in their complaining
towards the teacher – who consequently may experience stress.
— 30 —
•
School
It is the researchers belief that many teachers want their learners to perform well
academically. The fact that children with ADHD are often not able to selectively direct their
attention to the central task – resulting in their not understanding the work and not completing
homework tasks – may add to the stress teachers experience. Such levels of stress may be
elevated when teachers are confronted with complaints from other children. Teachers then,
in turn, call on parents to intervene and the stress on parents can increase as a result.
This cycle contributes to all the different systems placing more stress on the child and in turn
possibly exacerbating symptoms of ADHD.
FIGURE 2.1:
THE RECIPROCAL INFLUENCE OF THE SYSTEMS ON ONE ANOTHER AS ADAPTED
FROM
DONALD, LAZARUS & LOLWANA (2002:52), ACCORDING TO THE SYSTEMS
CONTAINED IN THE AFORE-MENTIONED SECTIONS.
Error!
The red arrows
indicate the
pressures
toward the child
MESO
FAMILY
• Resentment
• Tiredness
• Stress
• Anger
Complain
to parents
increased stress
CHILD
SCHOOL
• Stress due to problems
in class
• Lack of concentration
• Daydreaming
PEERS
• Bad social relationships
due to behaviour
• Child with ADHD is
unpopular
increased stress
Complain to teacher
— 31 —
The influence across systems21 is of significance in this study and could play a central role in
determining the outcome, as it ought to reveal any possible reinforcement (of the principals of
CCT) across systems. The relating symptoms of ADHD are not considered to be the sole
defining characteristics of the child with ADHD but in order to understand the impact of
ADHD, on all the systems, it has become necessary to include the description and influence
thereof. I however agree with O’Neil (2006:1) when he reports in the Irish Times: Labels are
sins against children. He continues to quote Dr Humphrey who is of the opinion that once a
child is labelled, the search for answers and the exploration of options are often discontinued.
This study supports the continuous search for optimal functioning and inclusive
conceptualizations of children with ADHD within all systems. It aims to empower – and not to
restrict. In the next section, assessment – which is one way of exploring treatment options –
is discussed.
2.4
CHILDREN WITH ADHD AND ASSESSMENT
In assessing children with ADHD, many factors need to be taken into account and no single
method of assessment should be regarded as sufficient for making a diagnosis.
Psychological assessment to determine if a child has ADHD is necessary as it could provide
evidence that the symptoms are in fact related to ADHD. It also offers the opportunity to
determine which subtype of ADHD is present and further assists the medical practitioner in
prescribing the correct medical treatment (Braaten & Felopulos, 2004:142-144).
Assessing a child with ADHD should start with a detailed prenatal history, as well as
information on early development. An investigation into the history of the child could point out
factors or genetics that may have had an effect on the development of the Central Nervous
System (CNS) of the child (Sadock & Sadock, 2003:1224).
Apart from the valuable information gained from the child’s prenatal history, direct
observations within different settings (usually the school and at home) where a child is
required to pay attention may also be included. The DSM-IV-TR requires that the diagnosis
of ADHD include ineffective functioning in more than one setting. The child’s school history
and teacher’s reports are needed to determine why difficulties are experienced at school, as
well as how different aspects of the child’s learning may further complicate development.
These complicating factors may be determined by looking at how the child relates to different
groups of people (peers or adults) as well as how she performs in structured versus free
21
The reciprocal flow of influences in the subsystems will be discussed in the conceptual framework found at
the end of this chapter.
— 32 —
activities. Observations from parents with regard to the child’s reactions towards them and
the siblings are also taken into consideration (Sadock & Sadock, 2003:1224-1225).
Once the prenatal history and observations can be integrated, a holistic view of the
presenting symptoms often becomes apparent.
The next step will then be to exclude
behaviour that may appear similar to ADHD, but are in fact very different, such as: normal
preschool activity levels, intellectual disability, hearing impairment, specific learning
disabilities, Autism – Asperger Syndrome, Epilepsy, Depression, brain injury and/or, family
dysfunction (Green, 1997:62-64).
Standardised measures could also be implemented. Parents and teachers could be
requested to complete questionnaires and checklists that usually contain statements
pertaining to ADHD. After completion a score can be obtained: the higher the score, the
greater the possibility that the child indeed has ADHD (Green, 1997:65). For the purpose of
this study, the parent as well as the teacher will complete the Copeland Symptoms
Checklist22.
When children are referred to a psychologist for assessment, it is most likely that an
intelligence test or a test of cognitive ability and academic achievement will be implemented.
(Braaten & Felopulos, 2004:145; Green, 1997:66-67). The afore-mentioned will rule out the
possibility of low intellectual ability being the cause of behavioural problems (Braaten &
Felopulos, 2004:145; Green, 1997:66-67). It will also give a preliminary indication of the
presence of ADHD, as most children with ADHD will often produce a characteristic pattern of
subscores on an intelligence test (Green, 1997:66-67). As part of the assessment battery, it
is advisable that specialised assessments in reading, writing, spelling, mathematics and
language are also included (Green, 1997:66-67).
For the purpose of this study, the Copeland Symptoms Checklist and CCB23 – which
measures, among other things, a child’s sensitivity towards internal and external distractions
– forms an integral part of the assessment. The Copeland Symptoms Checklist provides the
opportunity to measure whether there was any difference in the presenting symptoms before
and after implementation of the game. The CCB will give an indication of which
programme(s) of CCT needs to be facilitated in order to rehabilitate the cognitive structures
needed in order to function and adapt effectively to everyday life. Programme 3 – find the
shapes – will form the cornerstone of this study because these are the principles that the
board game is based on.
22
23
The Copeland Symptoms Checklist will be discussed in section 2.3.1.
The CCB will be discussed in detail in section 2.3.2.
— 33 —
2.4.1
THE COPELAND SYMPTOMS CHECKLIST24
Questionnaires, like the Copeland Symptoms Checklist, are designed to score specific ADHD
behaviours and the higher the child’s score, the greater the chances that ADHD is present.
Parents and teachers can complete these questionnaires (Green, 1997:65).
The Copeland Symptoms Checklist contains ten categories of symptoms:
ª
Inattention/Distractibility
ª
Impulsivity
ª
Activity level problems
o
Overactivity/Hyperactivity
o
Underactivity
ª
Non-compliance
ª
Attention-getting behaviour
ª
Immaturity
ª
Poor achievement
ª
Emotional difficulties
ª
Poor peer relations
ª
Family interaction problems (Copeland, 1987-2000:1-2).
These categories each contain a number of statements that the parent or teacher then
scores: Not at all; just a little; pretty much; very much (Copeland, 1987-2000:1-2). This could
provide a semi-objective input in the assessment and also aid in determining the effect of
therapy (Green, 1997:65).
2.4.2
AN INTRODUCTION TO THE CCB
The CCB is a psychometric test that is intended for children and adolescents, ages three
through to 16 (the last test, namely the Leveling-Sharpening-House Test, can be used with
adult populations) (Santostefano, 1988:3). It was standardized using a group of children from
age four through 12 years varying in ethnicity, socio-economic levels and geographic
locations. The children used in the standardization procedure were all well-adjusted and from
various public schools in the United States (Santostefano, 1988:31).
Even though the CCB was standardized in a foreign country, it is applicable for the South
African context: certain issues which are of concern have been addressed, namely language,
words, context and examples (Kanjee, 2001:87). With regard to language, the CCB was
24
An example of the Copeland Symptoms Checklist can be found in Appendix A.
— 34 —
standardized in English – which is also the home language and language of education of the
participants. In the CCB the words (colours and fruits, which are the same in South Africa)
and the context and examples used (i.e. colours of fruits) are universal.
The CCB was designed to measure and evaluate three cognitive functions namely, scanning,
attending selectively and comparing images of past information with present perceptions
(Santostefano, 1988:1). The cognitive functions are measured by means of three different
subtests:
ª
The Scattered Scanning subtest measures the manner in which a field of information
is scanned – narrow or broad (Santostefano, 1988:2).
ª
The Fruit Distraction subtest measures selective attention (Santostefano, 1988:3).
ª
The Level-Sharpening House subtest measures the comparison of images of past
information with present perceptions (Santostefano, 1988:3).
The above-mentioned cognitive functions play an important role in learning and if they are
dysfunctional, the result could be difficulties to adapt – and even learning problems (Davel,
1995:92). In such an instance the three tests will be used as a battery. The tests can also be
used individually for specific clinical or research purposes (Santostefano, 1988:3).
The
cognitive function relevant to this study is selective attention and the focus will thus be on the
fruit distraction subtest as an individual test. This test assesses the way in which a child
selectively directs attention when faced with a stimulus field containing information that is
relevant or irrelevant to the task at hand (Santostefano, 1988:49).
In order for children to engage in the Fruit Distraction Test (FDT), they need to be competent
in naming the primary colours (blue, red, yellow and green). Prerequisites for taking the FDT
would be the ability to identify a picture of an apple, a banana, grapes and lettuce.
In
addition they should be aware of the usual colour of both the fruits and the vegetable
(Santostefano, 1988:3).
The test consists of four cards that are presented to a child only after a practice example was
correctly completed (except for card three where no practice examples are given).
The
practice examples ensure that the abovementioned skills are in place. Each card contains 50
coloured rectangles or pictures of the fruit and the vegetable (in colours blue, red, yellow or
green) that are arranged in random order. This order is however similar for each of the four
cards. The child is then asked to name the colours of the pictures on the card as quickly as
possible (Santostefano, 1988:3).
— 35 —
i.
Card one: The card contains 50 rectangles in the colours blue, red, yellow and
green.
ii.
Card two: The pictures are yellow bananas, red apples, blue grapes and green
lettuce.
iii.
Card three: The pictures are also yellow bananas, red apples, blue grapes and
green lettuce, exactly the same as those of card two. The distinguishing feature is
the achromatic line drawings of various common objects that are placed in between
the fruit. These drawings are considered intrusive information that is irrelevant to the
central task. The child is asked to try to ignore these distracting stimuli and is then
asked to pay attention only to the colours and to name them as rapidly as possible
(Santostefano, 1988:3).
iv.
Card four:
The same pictures as in card two and three are presented.
The
difference being that they are coloured incorrectly. An apple may thus be green,
yellow or blue but not red. The child should then name the colours that should be
there as fast as possible (Santostefano, 1988:3).
Apart from the fact that the FDT assesses the cognitive function selective attention, each
card measures the specific type of distraction the child is sensitive to. The peripheral pictures
found on card 3 serve as external distractions and measures the child’s sensitivity towards it.
Card 4 measures sensitivity towards internal distractions through the contradictory colours on
it (Santostefano, 1998:58).
Assessing ADHD is a process that needs to take many factors into consideration if optimal
benefit is to be reaped. It should be seen as the first step towards treatment or intervention
as it will most likely create an opportunity to introduce aspects of the intervention and
familiarise and sensitise the child towards it. The results will give a good indication of the
best treatment option or intervention strategy, which in this study will be CCT.
2.5
ADHD AND INTERVENTION
In chapter 1 mention was made of a multi-disciplinary approach – including a combination of
medication, behaviour intervention and sometimes skills training – that currently appears to
be most effective in dealing with children with an attention problem (Goldstein & Goldstein,
1998:443). This study will however focus on CCT as behaviour intervention strategy, as
some parents may feel uncomfortable giving their child prescription drugs on a continuous
— 36 —
basis (Sears & Thompson, 1998:247). The researcher envisages that the implementation of
the board game may however provide the opportunity to examine the possibilities and options
with regard to medication use with the parents, while also empowering them in other areas of
the intervention process.
2.5.1
COGNITIVE CONTROL THERAPY (CCT)
2.5.1.1 What is Cognitive Control Therapy
CCT is an intervention strategy developed by Sebastiano Santostefano, the same person
who developed the CCB. The CCB and CCT were not intended to be used in isolation, but
rather to complement each other. The results obtained from the CCB acts as an indicator for
the different CCT programmes, which need to be implemented.
CCT as a therapeutic intervention is made up of five different programmes, each of which
aims to rehabilitate dysfunctional cognitive structures that a child needs in order to withhold
and direct attention selectively (Santostefano, 1995:5).
To accomplish this, CCT asks a child to deal with a series of structured cognitive
tasks which, in a stepwise fashion, attempt to improve the way in which a particular
cognitive function copies information, then considers that information from different
points of view, and then participates in transforming (i.e., pretending the information
is something else) (Santostefano, 1995:5).
CCT is an intensive programme that is practical and offers much opportunity for children to
acquire skills they can apply to everyday life. This study focuses on attention problems;
therefore the programme of interest is “Find the shapes”, which will be discussed next.
2.5.1.2 CCT relevant to the study – “Find the shapes”
Find the shapes makes up programme 3 of CCT and it is concerned with the rehabilitation of
the cognitive control “Field articulation”.
It defines the manner in which a child scans,
articulates, and responds to a field of information in terms of what is relevant and irrelevant
for the task at hand (Santostefano, 1995:128).
The goal of “Find the shapes” is to help the child develop the ability to distinguish relevant
from irrelevant information and withhold attention selectively from irrelevant information. The
information the child is confronted with during the therapeutic situation is presented in
— 37 —
concrete (as it is) format, and also in abstract (symbols or fantasies) format (Santostefano,
1995:129).
In this programme a field of information is created by using different pieces. These pieces to
be used in the therapy sessions as part of the research will include shapes (squares, circles,
triangles and rectangles) either in blue, yellow or red. The therapist instructs the child as to
which pieces of information are relevant to each specific task. The child reacts by either
locating the relevant pieces within the field or removing irrelevant information from the field.
There are seven steps (see table 2.2), each made up of a series of progressively more
difficult tasks (Santostefano, 1995:129).
TABLE 2.2:
THE STEPS OF THE PROGRAMME “FIND THE SHAPES”
Step 1
Geometric Shapes
Part A
Complexity of the field of information changes:
Part B
1.
From few shapes to many shapes.
2.
From shapes of one colour to shapes of many colours.
3.
From shapes located close to one another to shapes placed far apart on the table.
4.
From one type of shape to many types of shapes (thick and thin).
5.
From one size to many sizes.
6.
From single colours to patterns.
7.
From an orderly display to an unstructured display (heap of shapes from which the
child should identify a particular shape)
Increased complexity of dimensions that define the information as either relevant or
irrelevant.
1.
Part C
From one to many dimensions defining information as relevant/irrelevant, increased
by therapist.
Delay engaging in tasks with relevant information.
1.
From little delay to much delay.
2.
From simple to complex tasks.
Part D
Child and therapist evaluate behaviour.
Step 2
More complex information (buttons, paper clips).
Parts A – D Same as step 1
Step 3
Simple and complex information (other objects, such as puzzle pieces, pictures, playing
music, tape recordings of noise).
Parts A – D Same as step 1
Step 4
Information that can elicit fantasy and emotion is now introduced.
Parts A – D Same as step 1
Step 5
Information is now associated with other objects, for example, geometric shapes (red
squares) are imagined to be guns or cars, or yellow circles are imagined to be flowers.
— 38 —
Parts A – D Same as step 1.
Part E Child and therapist evaluate whether symbols constructed are conventional or
personal and the degree to which they fit attributes of stimuli (Santostefano, 1995:130).
Step 6
The therapist initiates role-play and child and therapist evaluates (use animal puppets).
The therapist utilises some of the fantasies the child used in the previous steps.
Parts A – E Same as step 5
Step 7
The child initiates role-play and transfers to the classroom. The therapist should actively
encourage real-life situations. No restrictions are imposed on the complexity of fields of
information or the dimensions defining information as relevant/irrelevant (Santostefano,
1995:130).
Adapted from Santostefano (1995:130); Eloff (1997:21-22)
These steps as well as the content of programme three will be adapted in such a way that it
can be incorporated in a board game, which should be user-friendly and enjoyable to the
family members who will implement it.
2.6
PARENTAL INVOLVEMENT IN AND BEYOND THERAPY
2.6.1
PARENT GUIDANCE
The earliest reference to parent guidance can be found in the beginning of the 19th century
when groups were formed for mothers to address issues relating to the problems and
practices of child rearing (Oberschneider, 2002:185). However, parents were only considered
as part of the therapeutic process with the introduction of psychoanalysis by therapists like
Anna Freud (Oberschneider, 2002:185). It was only much later that parents’ role in therapy
became more active in the sense that they were the ones who supplied information about
their children to the therapist, while the therapist gave them advice about handling their
children (Witmer, 1946:11).
The 1930’s and 1940’s brought about another change in the way parent guidance was
applied. This time it was believed that the child in therapy could only truly be helped if the
unconscious conflicts of the parents were explored and understood. In this sense parents
were seen as patients (Oberschneider, 2002:185). However, during the 1940’s the focus
shifted from parents as patients to parents as partners. This new focus was characterized by
a supportive relationship between therapist and parent and as a result more support was
gained from parents toward their child’s treatment. This supportive approach continued into
the 1980’s (Oberschneider, 2002:185).
Siskend (1997:14) placed the emphasis of parent guidance on the interpretation of
transference, (ambiguous feelings experienced by parents toward the therapist).
For
— 39 —
example the parents may view the therapist as their child’s saviour while being faced with
their own limitations concerning their children (Siskend, 1997:14).
On the topic of
transference Siskend (1997) writes:
Both the acting out of parents and the therapist’s countertransference are burdens
when resisted. When they are acknowledged and accepted by the therapist, when
they are pursued and explored with curiosity and energy, these unconscious
dialogues become valuable sources of insight and serve us well (Siskend, 1997:14).
Transference and countertransference are encountered in the psychodynamic approach –
which forms part of the theory on which CCT is founded. The viewpoint of this approach is
that a person’s mind has both unconscious processes and conscious awareness. These are
often conflicting and the meaning a person assigns to events or experiences is influenced by
them (Santostefano, 1995:xviii). This theory allows the therapist to examine the unconscious
meanings or influences that directs a child’s behaviour (thus therapists acknowledge, accept
and use the unconscious dialogues to the benefit of the child and of the therapeutic
intervention). This is done in the second phase of CCT, where fantasy and role play are
introduced (Santostefano, 1995:xxiii).
In his conclusion Oberschneider (2002:204) refers to the use of a combination of the
supportive approach and the exploration of transference. He refers specifically to those times
when parents’ emotional difficulties have likely contributed to or continue to exacerbate the
child’s emotional difficulties (Oberschneider, 2002:204).
To achieve this combination an
alliance with the parents should be formed from the start by listening, supporting and
preparing the parent or parents for the work ahead (Oberschneider, 2002:202) and by making
an effort to let parents feel understood, cared about, validated, and empowered (McGuire &
McGuire, 2001:2). It is important to remember that the goal for the use of transference is to
facilitate improvement in parenting as well as in the behaviour of the child by creating
opportunities for parents to gain awareness of unconscious factors that may have a negative
influence – at the same time CCT introduces these meanings to the child’s awareness. As a
result the child can be empowered to gain control over them (Santostefano, 1995:xviii). The
child however remains the patient – problems of parents are only explored if these have a
relation to the child’s problem (Oberschneider, 2002:202-203).
In this study the board game will serve as a link between therapist, parent and child. The
parent will be given the opportunity to take on different roles, one of these being co-therapist
in reinforcing the principles of CCT in the home environment. The possibility exists that the
board game will afford parents the opportunity to explore their own emotional responses with
relation to their children’s symptoms of ADHD. The therapist will support the parents in their
— 40 —
exploration process because they should understand and address their own emotions
regarding ADHD in order to enable them to fulfil their roles in the therapeutic process.
2.6.2
GAMES IN THERAPY
One of the strengths of games in the therapeutic context is that they can be used as a
substitute for verbalisation (when children are too young to verbalise their emotions) or as
fantasy expression (Schaefer & Reid, 2001:1; Schaefer & Cangelosi, 2001:9-10; Wilson,
Kendrick & Ryan, 1992:50-51). When a child engages in play therapy, playing a game can
promote the emotional growth of children in direct and indirect ways (Schaefer & Reid,
2001:11). Another advantage of the process of playing a game is that it may enhance social
skills, reality testing and mastery of anxiety, while at the same time offering enjoyment,
relaxation and catharsis. The therapeutic relationship may also be strengthened through the
playing of a game.
Moreover a metaphorical stage may be generated, facilitating the
expression and resolution of fear and conflict (Schaefer & Reid, 2001:11-12). A great wealth
of games is to be found within the play therapy context:
ª
Puppets (Kaduson & Schaefer, 2003:159; Schoeman & Van Der Merwe, 1996:132).
ª
Storytelling (Kaduson & Schaefer, 2003:178; Schaefer & Cangelosi, 2002:245).
ª
Finger Painting in play therapy (Schaefer & Cangelosi, 2002:205: Schoeman &
Van Der Merwe, 1996:176).
ª
Music Play therapy (Schaefer & Cangelosi, 2002:303 Schoeman & Van Der
Merwe, 1996:44).
ª
Sand play (Schaefer & Cangelosi, 2002:162; Kaduson & Schaefer, 2003:270;
Schoeman & Van Der Merwe, 1996:176)
ª
Ball Play (Schaefer & Cangelosi, 2002:313; O’Conner, 1991:203).
ª
Board games (Bellinson, 2002:2; O’Conner, 1991:210-211).
Board games are referred to as structured, goal-orientated games, with specific rules of
interaction dictating that there will be a winner (Bellinson, 2002:2; Schaefer & Reid, 2001:12). They allow children to play out their problems, and possible solutions in a non-threatening
age-appropriate environment (Bellinson, 2002:30) while attempting to relate the treatment to
the child’s real life (Bellinson, 2002:30). It would appear that children who have reached the
developmental stage where they can, to a large extent distinguish fantasy from reality, might
prefer to play board games in therapeutic sessions (Bellinson, 2002:3; O’Connor, 1991:207).
O’Connor (1991:207) is of the opinion that board games are of little interpretational value to
the therapist. However, the researcher does not share this view and prefers to align herself
with the views of Bellinson (2002:3), who argues that board games are developmentally
— 41 —
appropriate for children in the middle childhood phase. It should thus be expected and even
encouraged that they be used.
The fact that the board game aims to create a fun
intervention and may be enjoyed within the family context, serves to strengthen the
researcher’s view in this regard.
The board game used in this study will aim to accomplish all the afore-mentioned by:
ª
incorporating clear instructions and rules25 that will guide interaction;
ª
allowing children to become aware of their attention problems in a playful
environment, while at the same time acquiring skills (cognitive control) to apply in
everyday life (when required to direct attention selectively to a task at hand).
Of all the games mentioned here, a board game served the rationale and focus of the study
best. The researcher furthermore felt comfortable using a board game for involving the family
in therapy, but, more importantly, to extend therapy to their home environment. Board games
also appear to be the most age appropriate play therapy intervention considering that ADHD
– Predominantly Inattentive Type – is often only diagnosed during the middle childhood
phase. The impact of this game, however, does not only depend on its suitability for the
child, but depends equally on the co-operation of the parents. The role of parents with regard
to the board game will now be reviewed.
2.6.3
THE ROLE OF PARENTS WITH REGARD TO THE BOARD GAME
When parents make the decision to take their child for therapy, the emotions they will most
likely experience can be compared to those felt when they first took their child to pre-school
or to their first day in grade one (McGuire & McGuire, 2001:1). Parents in this vulnerable
situation need some comfort and reassurance. It is thus advisable that the therapist aims to
create a positive environment in which the parents feel they can trust the therapist and that
the therapist acknowledges the important role they play in their child’s life and in the
therapeutic process (McGuire & McGuire, 2001:1-2). This can be realised by establishing a
collaborative relationship with the parents.
When such a relationship is considered in therapy, a few aspects needs to be kept in mind,
especially when working with the family of a child who has attention difficulties. It is important
to realise and respect that every family is a unique system. Ideally families should be
empowered with knowledge in such a way that it is practical and also understandable to
them. Although families with children with ADHD are often very vulnerable to stress, it is vital
to remember and acknowledge that they too have learned to cope with their difficult
25
The instructions and rules of the game will be explained in chapter 3.
— 42 —
circumstances and thus can be regarded as the “experts” on their child’s life (Lock, Marthur &
Smith, 2003:1-2).
The use of the board game will be facilitated in a practical and understandable way and the
parents will implement it at home.
Their involvement could lead to their being more
motivated, which in turn could motivate their child. Involving parents in therapy may also
increase the commitment from the parents’ side, which could improve the overall success of
the therapeutic intervention (McGuire & McGuire, 2001:10-11).
The therapeutic situation envisaged for this study entails that the mother should take on
multiple roles, namely consultant, collaborator or co-client (Kendall & Choudhury, 2003:93).
These roles will manifest in the following ways:
•
Consultant
The mother will give information on the life and development of the child up until that point in
time. She will report back on the progress made at home after using the board game and
she will link with the school, the therapist, the child and the family system.
•
Collaborators
The mother will collaborate with the therapist by implementing the board game at home,
thereby reinforcing those skills facilitated by the therapist during the formal therapeutic
session.
•
Co-client
The principles of therapy as well as the use of the board game will be facilitated to the
mother, who will then implement them at home. She may also need guidance and support in
order to understand her child and her child’s behaviour as well as the concepts of the
therapeutic process.
Being part of this study places a tremendous responsibility on the mother’s shoulders. She
needs to make time to implement the board game and to fulfil al the above-mentioned roles.
The researcher will attempt to simplify the mother’s role and make it more accessible by
keeping an open channel of communication and encouraging her to ask questions at any
time. The researcher will also aim to give meaningful feedback on those questions or other
concerns the mother may have. The researcher will further attempt to enable the mother to
be optimally prepared for her multiple roles in this study by facilitating issues pertaining to
ADHD.
— 43 —
2.7
CONCEPTUAL FRAMEWORK
Figure 2.1 (see p. 31) showed a graphic representation of the negative influences of ADHD.
The conceptual framework that guides this study also provides for the positive aspects that
may form part of this study. Although still based upon the systems theory, the conceptual
framework for this study consists largely of assumptions. This is illustrated in figure 2.2 (see
p. 45).
The conceptual framework is largely based upon assumptions of the possible influence and
outcomes of the intervention process. Firstly the assumption is that an improvement may
become evident in each of the micro systems, which may be due to the inclusion of a fourth
micro system, namely the intervention (incorporating all the principals of Santostefano’s
theory) that could have the following influence on the other Microsystems:
•
Family:
ª
Empowered because of better understanding of their child
ª
Becomes aware of positive traits associated with ADHD.
•
School:
ª
Notices better behaviour in class.
ª
Becomes aware of positive traits by talking to parent.
•
Peers:
ª
Appreciate improvement in social skills and accept the child as a friend.
Another core assumption is that improved relationships between the different micro systems
may become apparent in the meso system.
This may be due to the individuals within
systems having more understanding and empathy for the situation of individuals in other
systems. It might emerge that systems become more understanding towards each other and
work together as a team.
Lastly, but of cardinal importance, is the influence of the child on the other systems and vice
versa. Firstly it its envisaged that the child (and the other systems) will discover and embrace
the positive aspects associated with ADHD –creativity, energy, spontaneity and an ability to
focus intently on the task chosen by themselves (Sears & Thompson, 1998:3).
— 44 —
FIGURE 2.2: THE CONCEPTUAL FRAMEWORK BASED UPON THE MODEL PROPOSED IN SECTION 2.3
MESO
Micro 1: Family
Empowered
through the
principles of
the game
Assumption 1:
- Empowered due to better
understanding of their child
- Become aware of positive traits
associated with ADHD.
Micro 2: School
Micro 3: Peers
Assumption 3:
- Notice better behaviour in
class.
- Become aware of positive
traits by talking to parent.
Assumption 2:
- Appreciate improvement
in social skills and accept
the child as a friend
CHILD
Micro 4: Intervention
Assumption 4:
- Empower child and family
- Principals acquired flows over to
other areas and / or systems
Improved
relationship
between
parent and
child
Discover
own positive
traits:
CHILD
Assumptions
pertaining to the child
Receive
positive
feedback
from other
systems
- Creativity
- Energy
- Spontaneity
- Ability to focus
intently
— 45 —
Furthermore, the following assumptions are made:
ª
Children will be empowered through the principles of the game.
ª
They will receive positive feedback from individuals in other systems.
ª
An improved relationship between parent and child could develop.
2.8
CONCLUSION
The aim of this chapter was to give the reader the opportunity to gain a greater
understanding of the impact and effect of ADHD. The ripple effect that ADHD has on every
aspect of a child’s life has brought to light the fact that ADHD permeates to complex
reciprocal challenges between the different systems involved. This reciprocity seems to exist
by default and it is evident that ADHD has to be addressed on meso-level. Probably the
greatest influence of ADHD on the systems is the manner in which it forces the negative
influences present in one system to flow over to and exacerbate the negative influences in
other systems. A vicious cycle emerges and this needs to be broken by involving all systems
in the process of assessment and intervention with the goal of empowering them.
Intervention becomes far more than child-therapist interactions and rather takes on the form
of co-operative facilitation, where the principles and skills applied in the therapeutic session
are carried over to other role players in an attempt to motivate them to apply such principles
and skills in their own system. The result could then be the reciprocal strengthening of
positive aspects and elimination of negative influences.
---oOo---
— 46 —
CHAPTER 3
THE DESIGN AND USE OF A BOARD GAME
IN CCT
3.1
INTRODUCTION
This chapter contains the guidelines and criteria that need to be taken into consideration
during the design of a board game.
These are then related to this specific game.
A
description of the contents of the board game, and the thinking behind its development are
given. An explanation of the rules of the game and the function of the different aspects of the
game follows. Chapter 3 will strive to equip the reader with all the knowledge needed to
understand the use and working of the board game as well as its application possibilities.
Chapter 3 strives to equip the reader with the knowledge needed to understand the use and
working of the board game as well as its application possibilities.
3.2
DEVELOPMENT OF THE BOARD GAME
During the course of my master’s studies I used CCT as therapeutic intervention strategy
with children who experienced attention difficulties. I enjoyed using CCT because of its
practical nature – its rationale made sense to me. During my time spent with children with
ADHD and using CCT, I noticed that there were times when the therapeutic process was
interrupted and needed to be sustained outside therapeutic sessions. Children were
sometimes not able to attend therapeutic sessions, which influenced the sustainability of
existing therapeutic progress. Often a child would show relapses in progress due to the
afore-mentioned and this prompted me to think of a way to extend the therapy beyond the
therapy room. It became clear that it would be useful to involve the parents in the process.
This encouraged me to explore different possibilities, which will enable parents to reinforce
the principles of CCT in the home environment. Many hours went into reflecting on this, as
our fast-paced life has created a culture where both parents work and time spent at home is
precious and scarce. The solution had to be something structured, yet fun, with realistic time
limits, so that it would not take up too much time; place a burden on the family; or complicate
family relations. I came to the conclusion that this process would be best facilitated using a
board game.
— 47 —
Finally the practical issues had to be considered and ways of incorporating the principles of
CCT into a board game needed to take on shape. Much moulding and shaping and many
drafts, resulted in a board game with cards and components all based on the principles of
either the CCB or on the CCT program “Field articulation – Find the shapes”.
3.3
THE DESIGN OF THE BOARD GAME
I viewed the design and development of a board game as an ongoing process. It is, in my
opinion, a gradual evolution of ideas, which does not emerge overnight. One of the biggest
considerations in the design process of the game was that it had to cater for the needs of
children with attention problems. The practicality and user friendliness of each aspect of the
game had to be measured against this fact.
Many resources are available to assist one in the process of game development. Dodge
(2003:1-5) outlines six steps that make up the process. His research has proven to be very
valuable in my quest to develop this board game and I will use his steps as basis to explain
this section.
3.3.1
CONTENT ANALYSIS
Content analysis involves a process of brainstorming on the topic you have in mind for the
game – either alone or, preferably, in a group. Any and all ideas (as many ideas as possible)
should be gathered and written down. Selecting the ideas that have potential and eliminating
those that may not work will be done later (Dodge, 2003:1).
The brainstorming phase of the developmental process was done, involving the following
people:
My supervisors: Both of them have extensive knowledge of CCT and they could
contribute by taking into consideration the principles of CCT as well as the
therapeutic context that the board game intends to mimic.
An educator: She has many years experience working with children and has a
wealth of knowledge on activities that children enjoy and on elements, which could
possibly enhance a board game.
A production manager:
His field of expertise is in creating processes for
manufacturing. He could contribute creative ideas about practical aspects that could
add to the applicability of the game.
— 48 —
The following ideas emerged during the brainstorming phase26:
Incorporating the shapes used in CCT.
Using generic concepts most children can relate to (e.g. ice-cream).
Having a start and a finish.
Using “punishment” – if you land on a certain block, or if you do/answer something
incorrectly, you have to be punished.
As punishment use a specific block like the jail in Monopoly(R) ®27.
Use “reward-blocks” together with punishment, for example: Dream Land, NeverDo-It-Again-Boat, Sorry City.
Add blocks that force you to skip a turn.
Use a points system where each player has an empty board that has to be filled with
objects. The player whose board is filled first, wins.
Design the blocks in such a way that each block represents a different object and
once you land on that block and do something correctly, you collect an object. Once
you have collected one of each object, you win.
Incorporate aspects that appeal to children, such as rainbows and smiley faces.
Use animals or insects that both boys and girls can relate to.
Use primary colours, as they can be used for boys and girls.
Incorporate concrete as well as abstract elements.
The game should be played by two players.
The game should be played by more than two players.
Use pawns to move along with.
A command should be completed correctly in three different ways before the player
can move on. Once the player makes a mistake, the other player gets a chance to
play.
The use of shapes should become more and more difficult.
Use cards that indicate which shapes should be used rather than using all the
shapes in every move.
The shapes can form part of the board, can be stored on the board and removed as
needed.
Use different blocks to indicate what shapes must be used during a turn.
At the end of the analysis phase I found myself being faced with a whole list of seemingly
unrelated possibilities; yet most of them appeared very promising. At this point, however, it
26
27
These ideas that emerged from the brainstorming session and not all of the ideas reflect the opinion of this
study, as external individuals were also involved. It may thus occur that some of these ideas are
contradictory to the views and opinions of this study.
This refers to the property trading board game developed by Metrotoy under license for John Waddington
Ltd. London & Leeds and this reference will be applicable throughout the chapter when referring to the game
Monopoly®.
— 49 —
became clear that a lot of thinking and planning would still have to go into the design process
and the final product would be the result of numerous trials – of which the next phase marked
the first step.
3.3.2
INCUBATION
During this phase the ideas generated previously are put aside for a period of time. Upon
returning to the list, new ideas and connections emerged that were previously not noticed
(Dodge, 2003:1). One of the magical things about creativity is that your mind works on
problems without you knowing it (Dodge, 2003:1).
This step came naturally to me. Earlier, once the initial thinking had been done I had some
trouble putting all the pieces together. I thought it a good idea to turn my thoughts away from
the list for a while. When I picked it up again I found myself feeling excited to work on it
again and two basic ideas started to take shape:
Design the game in the form of two boards – one for each player, based on an icecream theme. Each player has to collect different ice-creams by completing certain
commands and the player who collects them first wins.
Design the dice to indicate what should be done during the players’ turn.
Design the game like a “commercial board game” (such as Monopoly® and
Ludo®28 etc).
Use of blocks to move along on.
Use cards containing those aspects that relate to a specific block.
These blocks will determine what object you can collect if you complete it correctly.
Incorporate the attention game: “BLUEREDGREEN”.
Incorporate the attention game: “stand; sit; clap your hands; smile”.
3.3.3
CHUNKING
The list compiled in step one needed to be organised now: main categories are identified and
the words from the list are then arranged according to these categories (Dodge, 2003:1).
The categories identified by the author are:
•
Pieces
Items or objects that may be used as markers to move around the board or to keep score
with (Dodge, 2003:1).
28
This refers to the board game developed by Selchow & Richter in 1874 and this reference will be applicable
throughout the chapter when referring to the game Ludo®.
— 50 —
Patterns
•
This category refers to combinations: combinations of content, which take on a different form
or an additional meaning.
Paths
•
In paths reference is made to progression of events (Dodge, 2003:1).
Probabilities
•
Here the focus is on chance: does anything in the game happen by chance or beyond the
control of the player (Dodge, 2003:1)?
Prizes
•
What do the players strive for when playing the game (Dodge, 2003:1)?
Principles
•
How does the content work?
In table 3.1 the process of chunking in this study will be discussed.
TABLE 3.1:
Pieces
CHUNKING
•
Using generic concepts most children can relate to (e.g. ice-cream).
•
Incorporate aspects that appeal to children, such as rainbows and smiley
faces.
•
Use animals or insects that both boys and girls can relate to.
•
Use pawns to move along with.
In developing the board game used in this study these elements evolved from icecream to bugs to fish.
Patterns
•
Design the blocks in such a way that each one represents a different object.
Once you land on that block and do something correctly, you collect an
object. Once you have collected one of each object, you win.
•
Use cards that indicate which shapes should be used during a specific turn,
rather than using all the shapes in every move.
•
Use different blocks to indicate what shapes must be used during a turn.
•
Design the game in the form of two boards – one for each player, based on
an ice-cream theme. Each player has to collect different ice-creams by
completing certain commands and the player who collects them first, wins.
•
Incorporate the attention game: “BLUEREDGREEN”.
•
Incorporate the attention game: “stand; sit; clap your hands; smile”.
•
Using something children all relate to – ice-cream.
•
Incorporate aspects that appeal to children, such as rainbows and smiley
faces.
— 51 —
•
Use animals or insects that both boys and girls can relate to.
In this study the principles of CCT need to be reinforced, thus being connected to
certain aspects of the game.
Paths
•
The use of shapes should become more and more difficult.
In CCT, commands become progressively more difficult and paths need to be
established in order to allow for this progression in the game as well.
Probabilities
•
Add blocks that force you to skip a turn.
•
Design the dice to indicate what should be done during the players’ turn.
•
Use of blocks to move along on.
•
Use cards containing the aspects that relate to a specific block.
•
These blocks will determine what object you can collect if you complete it
correctly.
In this board game focus and involvement are very important and chance should
not play a role – other than perhaps rolling a dice.
Prizes
•
Using “punishment” – if you land on a certain block, or if you do/answer
something incorrectly, you have to be punished.
•
As punishment use a specific block like the jail in Monopoly®.
•
Use “reward-blocks” together with punishment, for example: Dream Land,
Never-Do-It-Again-Boat, Sorry City.
•
Use a points system where each player has an empty board that has to be
filled with objects. The player whose board is filled first, wins.
This category speaks for itself and was probably – in my mind – the most difficult
category to develop. Deciding upon a reward that will not shift the focus of the
game or complicate the game even further was very challenging. The use of any
form of punishment would also alter the principles of CCT (which state that
punishment should not form part of the therapeutic process). However, some form
of reward did seem necessary to motivate children to keep playing. A lot of
elimination happened during this stage before an acceptable reward was decided
upon.
Principles
•
Incorporating the shapes used in CCT.
•
Incorporate concrete as well as abstract elements.
•
Design the game in the form of two boards – one for each player, based on
an ice-cream theme.
•
Having a start and a finish.
•
Use primary colours as they can be used for both boys and girls.
•
The game should be played by two players.
•
The game should be played by more than two players.
•
The shapes can form part of the board, can be stored on the board and
removed as needed.
•
Design the game like a “commercial board game” (such as Monopoly® and
Ludo® etc.).
•
Design the blocks in such a way that each block represents a different object.
•
A command should be completed correctly in three different ways before the
player can move on. Once the player makes a mistake, the other player gets
a chance to play.
•
Use cards that indicate which shapes should be used during a specific turn,
rather than using all the shapes in every move.
— 52 —
•
Incorporate the attention game: “BLUEREDGREEN”.
•
Incorporate the attention game: “stand; sit; clap your hands; smile”.
This board game will be based on the principles of CCT and therefore elements of
CCT were included here.
3.3.4
ALIGNING
The content identified up until this point now needs to be examined in order to decide what
should be taught by the game and which elements of the content can be aligned with the
structure of the game (Dodge, 2003:2).
In this game the rehabilitation or acquisition of the cognitive control “Field articulation” needs
to be facilitated. The focus of the game is also on the improvement of concentration.
TABLE 3.2:
ALIGNMENT BETWEEN THE GAME (CARDS29) AND CONTENT (CCT)
Bunny Cards
30
CCT
Facilitate the acquisition of the cognitive
control ‘Field articulation’ through the use of
the names of colours (irrelevant) printed in a
colour (relevant) different to that which it
represents.
Aims to rehabilitate dysfunctional cognitive structures
by developing the child’s capacity to direct attention
selectively at complex fields and configurations of
information in terms of dimensions of
relevance/irrelevance (Santostefano, 1995:129).
Bear Cards
CCT
Facilitate the acquisition of listening skills
and of paying closer attention to a task at
hand by asking a child to perform tasks that
are simple at first but later incorporate some
emotions.
Butterfly Cards
Facilitate the acquisition of the cognitive
control “Field articulation” by making use of
a deck of cards indicating specific shapes
(differing in contours, colour, spatial
relations and size) that are relevant to a
particular turn in the game.
Aims to promote the efficiency of field articulation
functioning by transforming information through the
use of fantasy or emotion (Santostefano,
1995:129,137).
CCT
Facilitate the acquisition of the cognitive control “Field
articulation” by making use of complex organisations
of contours, colours, spatial relations, and sizes to be
surveyed (Santostefano, 1995:129).
Dodge (2003:2) cautions the designer to keep the following rules of congruence in mind
during the aligning phase:
29
30
A detailed discussion of the cards can be found in section 3.6.3.
Some confusion may arise when children refer to a bunny as a rabbit. The facilitator should discuss this with
the child at the beginning of the game by highlighting that this game uses the word bunny.
— 53 —
Whenever possible, the structures of the game should mirror the structures of the
content; and The structures of the game should never contradict the structures of
the content (Dodge, 2003:2).
The structures of the board game should mirror that of a CCT session. For this reason all
elements included in the game tend to lend themselves to this mirroring and to not shifting
the focus of the players. All the structures encourage players to pay attention and they offer
the opportunity for players to realise that paying attention (1) is possible, (2) is fun, and (3)
pays off.
3.3.5
DRAFTING
During this step a rough prototype starts to take shape, being drawn on sheets of paper. Any
objects can be used as tokens or pawns allowing the game to be played. What is critical to
this step is reflecting upon possible thoughts of the players while they are playing the game
(Dodge, 2003:3).
The first draft took on the form of two boards – one for each player, based on an ice-cream
theme. They were connected to each other to form one board. A dice indicated to players
what should be done during each turn. Each player had to collect different ice-creams by
completing certain commands and the player who collected them first would win.
Although this seemed like a good idea, I could not figure out a way of incorporating the
commands in the game in such a way that the game would operate smoothly. It felt as
though the game did not operate as a unit, as all the commands were random or
disconnected activities, which appeared to be forced into the game. This did not serve the
purpose, as the game used in this study should get the players focused on becoming aware
of their own thoughts and focusing attention. The game should form a tight unit allowing
players to feel comfortable while enjoying the game. On this note however it was time for the
next step.
3.3.6
INCUBATION
During the final step of the initial process the subconscious has to do some work again while
the draft prototype is put aside (Dodge, 2003:3-4).
After this a process of refining and
improving follows playing the game with as many people as possible (Dodge, 2003:4).
During my own process of development I found this step to consume the most time and
effort: the draft prototype from the previous phase had to change many times to
— 54 —
accommodate issues picked up while playing the game. The issues I needed to address
were those of designing the game to work as a unit and of incorporating all aspects in such a
way that they would be easy to understand and the game would be fun to play. All aspects
of the game came under constant scrutiny and few things remained as set forth in the
original draft.
Nevertheless this was one of the most exciting phases because I could see the original idea
growing and being transformed into something with enormous potential. Upon returning to
the initial draft after the incubation period – and after consulting my chunking list again – a
whole new idea and concept started to take shape. A board game (such as Monopoly® and
Ludo® etc) came to mind and I started to adapt my original draft to fit onto a board. Where I
had initially thought it would be impossible because there were too many aspects to be
incorporated, I now realised that it would be possible after all:
I used a rectangular board with spaces around the edges along which a pawn could
be moved.
Every block was fitted with an identifiable object (bunny, bear or butterfly).
Decks of cards containing the same objects were used as a means of storing the
content of the commands; they indicated what should be done during a specific turn.
After much thought and ‘trial-and-error’, the cards were placed in numerical order
and ranged from easy to more challenging levels, in order to provide the increased
difficulty that characterises CCT.
During this step the “ice-cream” theme made way for an “animal” theme. After drawing up a
draft “ice-cream prototype”, it ended up looking too feminine owing to all the pastel colours.
The animal theme, on the other hand allowed the use of primary colours that appeared more
suitable for children of both genders.
The final product, after months of slowly progressing through the above steps, was a
colourful board game that incorporated all the elements of CCT. The content of this final
product will now be discussed.
— 55 —
FIGURE 3.1:
A PHOTOGRAPH OF THE DRAFT PROTOTYPE OF THE BOARD GAME
Start / Finish
Fish pawns
Bunny Cards
Player 1 – Bear &
Butterfly cards
Circles around the
edge of the board
Four colored
blocks
Shapes
Player 2 – Bear &
Butterfly cards
3.4
CONTENTS OF THE BOARD GAME
3.4.1
THE BOARD
In designing the board, my greatest concern was simplicity. The board should not contain
too many distractions since it will mostly be used with children with ADHD. Developmentally
it should appeal to children in the middle childhood phase, because of high prevalence rates
of children with ADHD in this age group. It is also the age group where there is a high
likelihood that children with ADHD will be in therapy31.
I decided to keep the board rectangular in shape like most board games. It should not
confuse the child by being too novel. The board is divided into four blocks, each being of a
different colour: red, yellow, blue and green. I chose these colours because:
31
Compare section 1 in chapter 1 for statistics on the prevalence of ADHD.
— 56 —
The same colours are also used in CCT, which helps to promote the mirroring of the
therapeutic situation.
Primary colours are usually accepted well by children and result in an inviting
appearance.
These colours are gender-friendly in that they do not necessarily appeal to only a
specific gender, as may be the case with certain pastel colours.
Still continuing with the same colour scheme, circles were added along the edge of the
board. Circles in the four colours mentioned above were placed around the edge of the
board in random order. These are used to guide the movement of the game from start to
finish and the number of circles a player will move along are determined by the score on a
dice thrown. The board also indicates which deck of cards should be placed where, as can
be seen in the following schematic representation:
FIGURE 3.2:
A GRAPHIC REPRESENTATION OF THE BOARD
Circles for moving on the board
Space for the “bear” and “butterfly" cards
Space for the deck of “bunny” cards
3.4.2
THREE DECKS OF CARDS32
The game includes three decks of cards, each covering different principles of CCT. The
three decks are distinguished by being referred to as “Bunny cards”, “Bear cards” and
“Butterfly cards”
The cards make up the core of the game as they:
consist of the principles of CCT that needs to be reinforced;
indicate what should happen during each turn; and
simulate the therapeutic session because they also become progressively more
difficult.
The inclusion of the cards in the game and deciding on an animals/insect theme as indicators
for the different decks was a gradual process and changed many times. I finally decided on
Bunny, Bear and Butterfly as each of these:
32
The rationale behind every different type of card is discussed in section 3.6.3.
— 57 —
start with the letter “B”, which makes it easier to remember;
represents an animal from different spheres of the animal (insect) kingdom (there
should be at least one that every child can relate to).
This will hopefully aid in the fun and enjoyment of the game.
3.4.3
SHAPES
FIGURE 3.3:
A GRAPHIC REPRESENTATION OF THE SHAPES USED IN THE BOARD GAME
These shapes are used to build certain figures according to commands33. They are the
same shapes and colours used in CCT and form the basis of CCT’s programme 334,
representing the main principles for rehabilitating the dysfunctional cognitive structures found
in children with ADHD.
3.4.4
PAWN
As the theme of the board game is animals, I wanted to stick to that, yet the pawns needed
to be clearly distinguishable from the other animals. Fish represented a sphere of animals
that had not yet been used, and I included one Blue fish and one Orange fish.
3.4.5
DICE
Because there is spaces around the board that need to be followed in order to reach the end,
a need arose for some type of measure to guide the process. A dice is a standard way of
doing this (Sloper, 2002:3), so a dice was included, as it should be familiar to most children
and will therefore be easy to use without complicating the game. A few well-known games
that make use of dice are: Monopoly®, Ludo®, Backgammon® and Trivial Pursuit®. A dice
should also add excitement to a game because you want to achieve higher scores than your
opponent in order to reach the finish first.
33
34
The use of the shapes will be discussed in section 3.6.3.3.
Compare chapter 2 section 2.4.1.2 for a discussion on the use of the shapes in CCT and table 2.2 for the
steps in CCT.
— 58 —
3.4.6
PLAYERS
I decided to design the game for two players. The reason is that two players may increase
the mimicking value of the game because there are also two people present in a CCT
session. It may also add to the game being more focused. The interaction between the two
players will be much more intense than when many players take part. This will enable the
parent who plays with the child to monitor any progress much better.
3.5
INSTRUCTIONS
All the players start at the beginning.
The first player to reach the END is the winner. (See alternative ways to play the
game).
Each player receives two decks of cards (“Butterfly” and “Bear”). These are used to
give commands to the other player.
Each player gets a chance to throw the dice.
The player who throws the highest score on the dice will start by moving the number
of circles as indicated by the number of dots on the dice.
The picture displayed on the circle on which the pawn lands indicates the type of
card to be selected by player 2.
If player 1 lands on either a “Butterfly”, or on a “Bear” circle, player 2 gives the
command.
If a command is not executed correctly, another command of the same nature
should be given, to a maximum of three commands per turn.
If a command is correctly executed, player 2 will throw the dice and player 1 will give
the instructions.
Play continues until the first player reaches FINISH (or according to the rules of
“Alternative ways to play the game”).
3.6
RULES OF THE BOARD GAME
3.6.1
THE BOARD
The yellow and the green blocks represent the areas in which each player will place
his/her playing cards. Before the game can commence, the two players will have to
decide who will be playing from green and who will be playing from yellow.
— 59 —
The green and yellow blocks each contains two smaller blocks.
These blocks
represent the designated spaces for placement of the decks of “Butterfly” and “Bear”
cards.
In the middle of the board, a small black square can be found. It represents the
designated space for the “Bunny” cards.
The circles around the edge of the board represent the spaces on which the players
will move their pawns. Each circle contains a picture (“Bunny“, “Bear“, “Butterfly“)
that indicates the card to be used.
When a player lands on a blank circle he/she skips a turn.
3.6.2
THE CIRCLES AROUND THE EDGE OF THE BOARD
Each circle contains a picture (“Bunny“, “Bear“, or “Butterfly“). The picture on the circle
indicates the type of card (“Bunny“, “Bear“, or “Butterfly“) corresponding to the deck of
command cards to be used during the particular turn when the player lands on that circle.
The pictures correspond with the following cards:
3.6.3
(Bunny)
-
Colour cards
(Bear)
-
Command cards
(Butterfly)
-
Shapes cards
(Blank)
-
No action, wait for your next turn.
DESCRIPTION OF THE CARDS
3.6.3.1 Bunny cards
The Bunny cards facilitate the acquisition of the cognitive control “Field articulation” through
the use of the names of colours (irrelevant) printed in a different colour (relevant). The
“Bunny” cards can be aligned with CCT35 because CCT facilitates the process of paying
selective attention to relevant information while ignoring irrelevant information (Santostefano,
1988:7).
The “Bunny” cards were adapted from an internet based game named “Color Contest Child
Game” and is used to improve concentration (Joubert & Joubert, 2003-2004:1).
The
website36 allows parents, educators and children the opportunity to copy and use the games
in their own situations. The reason I chose to include this game is because:
35
36
See section 3.3.4 and table 3.2 in this chapter.
The website address where the Color Contest Child Game and other similar games can be found is:
http://www.educational-toy-guide.com/childgame.html
— 60 —
it forces players to distinguish between relevant and irrelevant information;
it is fun, yet very challenging; and
it offers the opportunity to change it according to your needs and I was able to
create many different cards based on this game.
FIGURE 3.4:
A GRAPHIC REPRESENTATION OF THE BACK OF THE BUNNY CARDS
These cards contain the names of the colours red, blue, green and yellow written out. Each
colour name is printed in a colour that does not correspond with the colour name, for
example:
bluegreenyellowred
These cards are placed in the centre of the board and are used by both players.
When a player lands on a bunny circle, he/she must pick up a bunny card and
proceed by calling out the colours and not the colour names printed on the card.
The player should not read the names of the colours printed on the card.
If the above-mentioned example is used, the player calls out the actual colours, i.e.,
“red, yellow, blue, green” and not the names of the colours.
3.6.3.2 Bear cards
The Bear cards, just like CCT, aims to facilitate the improvement of paying attention to a task
at hand – as well as the acquisition of listening skills – by asking a child to perform a task
that is simple at first but later incorporates some emotions.
These cards were derived from an activity found in a treatment book for ADHD. I chose to
include it in the game because it does not only facilitate selective attention (a child needs to
attend to the other player when the command is read to be able to execute it), but it also
aims to develop listening skills – one of the most important skills a child needs in order to
adapt in the classroom situation (the child has to listen attentively to hear all the different
commands crammed into one sentence).
The goal of these cards is to encourage the
acquisition of listening skills in a fun way so that it may be more acceptable to the child with
— 61 —
ADHD (Dennison, 1990:330). The commands on these cards may help children to realise
the benefits of maintaining attention to a task (Dennison, 1990:330).
FIGURE 3.5:
A GRAPHIC REPRESENTATION OF THE BACK OF THE BEAR CARDS
The commands found on these cards are in a specific order (numbered from 1 to 24) and
progress from easy to more difficult. Examples are:
Sit, stand, put up your right hand
Turn around, put up your left hand, sit, fold your legs,
smile, stick out your tongue
If player 1 lands on a bear circle, player 2 has to pick up a bear card from his/her deck and
read the command slowly to player 1. The commands on the card need to be read as a unit,
and player 1 needs to memorise the commands as they are being read.
After Player 2 has read the commands on the card, Player 1 has to execute the
command.
If player 1 executes the command correctly he/she can wait for their next turn.
If player 1 executes the command incorrectly, player 2 should give another
command of the same nature (to a maximum of three commands per turn).
If player 1 cannot complete the command correctly after three attempts, the previous
card must be repeated the next time player 1 lands on a bear circle.
3.6.3.3 Butterfly cards
The Butterfly cards contain the same shapes, in the same colours, as those used in CCT.
Through the use of these shapes (differing in contours, colour, spatial relations and size), the
cards aim to facilitate the acquisition of the cognitive control “Field articulation”
(Santostefano, 1995:129).
— 62 —
As the shapes contain the main principle of CCT and serves an important role in mimicking
the therapeutic situation at home, they are included in the game. These cards forms the
direct link between parent and therapist, home and therapy room and it is here where most of
the reinforcement and increased sustainability for CCT should occur – because it is such a
true replica of what happens in therapeutic sessions.
FIGURE 3.6:
A GRAPHIC REPRESENTATION OF THE BACK OF THE BUTTERFLY CARDS
These cards consist of different shapes in different colours. Once more the cards are in a
specific order (numbered 1-18) and progress from easy to more difficult sequences of
shapes.
FIGURE 3.7:
AN EXAMPLE OF THE SHAPES FOUND ON THE BUTTERFLY CARDS
When player 1 lands on a butterfly circle, player 2 picks up a butterfly card from
his/her deck and gives a command using only the shapes showed on the card, for
example: “Put the blue square on the blue circle.”
Player 1 then needs to execute the command using the shapes included in this
game.
If player 1 executes the command correctly he/she can wait for their next turn.
If player 1 executes the command incorrectly, player 2 should give another
command of the same nature (to a maximum of three commands per turn).
If player one cannot complete the command correctly after three attempts, use the
previous “butterfly” card the next time player 1 lands on a “butterfly” circle.
— 63 —
3.7
ALTERNATIVE WAYS TO PLAY THE GAME
Instead of only playing one round at a time, the players can also determine
beforehand that a certain number of rounds will be played and that the first player to
finish the predetermined number of rounds will be the winner.
Once the game has been mastered, the players can start to give “mirror feedback”
to each other. Mirror feedback is where player 2 tells player 1 exactly how he/she
has executed a specific task. An example of mirror feedback could be “I saw that
you looked at me, then picked up the blue square, looked around and placed the
blue square on top of the blue circle and then you smiled.”
3.8
CRITICAL REFLECTION
After completing the prototype, I started to realise that all the effort that went into this game
contributes a rather small percentage towards the success that will be experienced by using
this game. I began to realise that the way in which this game is going to be introduced and, in
a sense be “marketed”, to the parents may play an equally important role. In the end it is the
parents who will have to make time to incorporate this game into their schedules.
One of the aspects of the game that I am not yet satisfied with, is the pawns. I shall continue
to search for something more applicable and which have more relevance to children in the
middle childhood phase. Overall, however, I feel satisfied with the layout of the game. I
experienced it as being user-friendly and enjoyable. I also accept that this game will in all
probability never be “completed”. New ideas and concepts will most probably continuously
emerge and then be incorporated into the game in the quest for continuous improvement.
3.9
CONCLUSION
This chapter introduced the reader to the board game used in this study. It is clear from this
chapter that the development of a board game is a complex task that requires patience and
perseverance. It is an ongoing process that challenges developers to question every aspect
of their own creation. Every part of a game should be significant and add value. It should
also work together to form a tight unit that supports the goal of the game. The development
of a board game is a fun, frustrating and exciting process, which probably teaches the
developer as much as it hopes to teach those who will play it.
---oOo---
— 64 —
CHAPTER 4
DISCUSSION OF THE RESEARCH PROCESS
4.1
INTRODUCTION
In this chapter the researcher describes the research process utilized to study how a board
game was used as a parent guidance strategy to reinforce CCT in the home environment of
the child with ADHD. A discussion of the case study is provided followed by a description of
the quantitative findings and qualitative insights which emerged.
An integration of both
qualitative and quantitative data concludes this chapter.
RESEARCH PROCESS37
4.2
The research process and design were described in detail in chapter 1. In order to provide
the reader with a summary of this process a graphical representation follows:
4.2.1
NOTES ON THE QUALITATIVE DATA COLLECTION
•
Therapeutic sessions
The data obtained from field notes made on a continuous basis during the therapeutic
sessions was transcribed and provided a rich source of data. A clear pattern of improvement
was evident. From this source of data however, it is not possible to determine whether the
improvement was the result of a combination of CCT and the board game, or of one of the
two.
•
Feedback from teachers
Discussions with some of Mary’s teachers were held after therapy was terminated. Field
notes were taken and transcribed, offering information on the impact of CCT and the board
game in the school environment.
37
Compare chapter 1 sections 6.2–6.4 for a detailed discussion of the research process.
— 65 —
RESEARCH DESIGN
CASE STUDY
MIXED METHODS APPROACH
DATA COLLECTION
QUANTITATIVE DATA
COLLECTION
PRE TEST
•
•
QUALITATIVE DATA
COLLECTION
POST TEST
CCB
Copeland
Symptoms
Checklist
•
•
•
THERAPEUTIC
INTERVIEW WITH
PROCESS
MOTHER
Observations
Therapeutic
notes
Therapeutic
progress
FEEDBACK
•
•
•
•
From mother
(parent guidance)
School
Therapeutic
sessions
Child
INTEGRATION OF QUANTITATIVE
AND
QUALITATIVE INSIGHTS
— 66 —
•
Feedback regarding the process of implementing the board game
The feedback I received from the mother was very limited and it was often difficult to
schedule an appointment with her. She communicated her experiences of the process to me
by means of two e-mails that consisted of one or two sentences. The information contained
in the messages was, however, insignificant and was thus not included in the data analysis.
•
Interview with the mother
The interview with the mother was conducted after therapy had been terminated and
appeared to be a significant source of information.
It assisted in determining how the
process of implementing the game at home was experienced by the family and also what
effect it had – in their opinion. This interview was transcribed and qualitative insights derived
from it.
4.2.2
DATA ANALYSIS
The qualitative data (gathered from the interview with the mother, field notes and
observations of therapeutic sessions and of the intervention) was analysed according to
Tesch’s model (Tesch, 1990:154-155):
ª
The data analysis was initiated by carefully reading through the transcriptions of the
interview and the therapeutic sessions to gain a holistic understanding. Some ideas
were written down – as they came up – during this step.
ª
Next the data was perused for purposes of identifying underlying meaning in the
information. The ideas that emerged were written in the margin.
ª
After reading through all the data a list was compiled containing all the qualitative
insights38. Clusters were then formed from similar insights.
ª
The list was then compared to the data and qualitative insights were identified by
highlighting the different sections in different colours and assigning a code to each
cluster by using an abbreviation of the cluster name.
ª
The researcher aimed to reduce the total list of categories by grouping together
qualitative insights that are related to each other, connecting similar insights with
lines indicating interrelationships.
38
Compare section 4.4.2 for a discussion of the qualitative insights.
— 67 —
4.3
DISCUSSION OF THE CASE STUDY
4.3.1
BACKGROUND OF THE PARTICIPANTS39
Mary was referred to the Training Facility of the Department of Educational Psychology
(University of Pretoria) because her parents were concerned about her academic
performance and they wanted to investigate the possibility that Mary had ADHD.
The participants are Mary, a nine-year-old girl, and her mother. Mary is the youngest of two
children (she has an older brother) who lives with her mother and father. The family moved
from Port Elizabeth to Pretoria in 2005. Mary’s brother did not move to Pretoria immediately
and stayed with a relative in Port Elizabeth to finish his academic year. He joined his family
in 2006, the year the family embarked on the intervention process. The parents reported that
the relationship between Mary and her brother was challenging from time to time.
The family’s mother tongue is English. Mary attends a government school where she is in
grade four and her mother is employed full-time by a government institution.
Mary is
currently experiencing difficulties in school; she is not performing well academically and her
relationships with her peers seem to be compromised due to the symptoms of ADHD.
4.4
DISCUSSION OF RESULTS
4.4.1
QUANTITATIVE RESULTS
4.4.1.1 CCB - FDT
In reporting the results of the CCT the percentiles (obtained together with the T-scores) of
the participant are discussed based on the scoring and interpretation guidelines described
later in this section40. An analysis of Mary’s pre and post test is done by referring to the
profiles derived from the assessments.
The T-scores for the FDT are interpreted in terms of six levels: severe (T-scores of 35 or
lower, associated with the lowest 7% of the population); moderately severe (T-scores of
between 36 and 40, percentiles of 8-16); and borderline dysfunctions (T-scores between 41
and 45, percentiles between 18 and 31); normal (T-scores between 46 and 55 – interpreted,
in general, as age appropriate field articulation functioning); above average functioning (T-
39
40
For documents supporting the facts mentioned here, see Appendix B.
lso compare chapter 2 section 2.3.2 for a detailed discussion on the scoring and interpretation.
— 68 —
scores between 56 and 65, percentiles between 73 and 93); and hypermature dysfunction
(T-scores 66 and above) (Santostefano, 1988:58).
GRAPH 4.1:
MARY’S PROFILE FOR THE CCB PRE TEST41. THIS PROFILE SHOWS THE TIME USED
AND THE ERRORS MADE ON CARD 2
42
(COLUMNS ONE AND TWO) AS WELL AS CARD
3 (COLUMNS THREE AND FOUR) AND CARD 4 (COLUMNS FIVE AND SIX)
The profile of card 2 gives an indication that the speed with which Mary approaches new
tasks is appropriate for a child of her age.
The number of mistakes she makes when
confronted with new tasks, however, falls in the borderline category and indicates that she
makes more mistakes than the average child of her age when confronted with new tasks.
It is important to note that the scores of cards 3 and 4 should be interpreted by comparing
them to the scores of card two, the baseline card as well as clinical data such as behaviour
41
42
The profile may be misleading as it is not presented here in conjunction with the qualitative data. It may thus
give the indication that the severity of the symptoms is low while the qualitative data serves to emphasize the
severity.
Compare chapter 2 section 2.3.2 for a discussion of how each card is used and what it evaluates.
— 69 —
changes or peripheral recalls. The percentiles indicate that Mary was able to name the
colours of card 3 in less time than that of card 2 (in other words at a faster rate) and she
worked more accurately (in other words made fewer errors) than she did compared to the
baseline card (card 2). The profile of an increased effort with regard to time and accuracy
when confronted with external distractions together with the qualitative data (the three
peripheral recalls and behaviour changes such as impulsivity, losing her place or skipping
rows, shouting or using her finger to point while attempting card 3) indicated sensitivity
toward external distractions and that she conversely experiences difficulties in withholding
her attention selectively from external distractions.
During the pre test, card 4 indicated a slight upward movement with regard to time and
errors. This may indicate sensitivity towards internal distractions. The interpretation of this
profile is supported by the Copeland Symptoms Checklist, the interview with the mother and
observations made by the different role players (researcher, mother and teacher).
GRAPH 4.2:
MARY’S PROFILE FOR THE CCB POST TEST. THIS PROFILE SHOWS THE TIME USED
AND THE ERRORS MADE ON CARD 2 (COLUMNS ONE AND TWO) AS WELL AS CARD 3
(COLUMNS THREE AND FOUR) AND CARD 4 (COLUMNS FIVE AND SIX)
— 70 —
These scores indicate that Mary used less time and made fewer errors in the post test when
confronted with a new task. It is, however, important to note that percentiles of 95> should
be given special attention. Percentiles in the range of 95> indicate the highest degree of field
articulation and may cause Mary to isolate her attention from distraction to an extreme
degree that could be as maladaptive as an inability to selectively withhold attention from
distractions (Santostefano, 1988:58). On the other hand, however, it may hold benefits for
Mary in the school environment, as it will be beneficial if she pays proper attention when new
work is done in class. It is important to keep in mind that even though there was a timeframe
of more than six months separating the two tests, Mary had been exposed to the test
previously and the changes in the profile may, to a certain degree, relate to this. Mary was
furthermore sensitized to the challenges posed in the test through the therapeutic process
and playing the board game as similar components are contained in it.
The percentiles from the post test indicate a significant drop in the profile, and even though
the scores are found in the normal range, the difference between cards 2 and 3 indicates a
possibility that a strong presence of sensitivity towards external distractions still exists. This
possibility is supported by the fact that she recalled four peripheral figures which equals the
cut-off score and is therefore viewed as significantly elevated (Santostefano, 1988:55). The
fact that Mary had taken the test before – and had consequently seen the peripheral figures
before – also needs to be kept in mind here.
During the post test Mary took longer to name the colours of card 4 in comparison to card 2,
which indicates that sensitivity towards internal distractions may still be present. She also
made more mistakes, as with the pre test, which serves to support the indication of internal
distractibility.
The results from the CCB thus showed that an improvement is evident in the way Mary
attends to new tasks. However, her ability to selectively direct attention to the task at hand –
when confronted with both external and internal distractions – after the therapeutic
intervention and the introduction of the board game in her home environment remains
problematic.
When comparing the profile of the pre test with that of the post test,
deterioration becomes evident with regard to cards 3 and 4. On card 3 Mary took longer and
made more mistakes in the post test than in the pre test – possibly indicating an increase in
the severity of her sensitivity towards external distractions. Comparing the scores of the pre
and post test of card 4 also reveals deterioration. Mary used less time to complete the card,
yet made more errors in the post test. This may indicate the possibility that she is aware of
her own sensitivity towards internal distractions and attempts to handle this by working faster
– at the expense of accuracy. In the classroom environment this could have serious
— 71 —
implications for Mary’s ability to focus on the work being taught and on her accuracy when
completing her schoolwork. The deterioration may be an indicator for a multi-faceted
treatment approach (such as medication, individual learning support and intervention in the
school environment). However, the parents were, at the time of assessment, not comfortable
with the inclusion of medication and wanted to implement other options first. It may also be
that the time-span of the CCT intervention may have been lengthened in order for Mary to
fully benefit. A CCB profile is after all only an indication of cognitive control functioning at a
specific point in time.
4.4.1.2 Copeland Symptoms Checklist
The Copeland Symptoms Checklist was also used as a pre and a post test. Mary’s mother
and teacher completed it before and after therapy. Each section of the questionnaire carries
a different weight as indicated on the checklist.
To obtain scores for each section, a
percentage is worked out by dividing the weight assigned by the person filling out the
checklist, by the weight assigned to the specific section. These percentile scores will be
used in discussing the results of the Copeland Symptoms Checklist and will be represented
in tables 4.1 and 4.2, followed by a graphic representation in the form of a histogram.
TABLE 4.1:
SCORES FROM THE COPELAND SYMPTOMS CHECKLIST FOR THE PRE TEST AND
POST TEST COMPLETED BY MARY’S MOTHER
Inatt
Imp
Hyp
Und
Non
Att-g
Immat
P-ach
Emot
Peer
Fam
Pre test
48%
47%
39%
33%
33%
11%
0%
48%
4.2%
17%
50%
Post test
47%
28%
18%
13%
27%
6%
8.3%
33%
4.2%
11%
29%
Key for reading Table 4.1
Inatt
Inattention
Immat
Immaturity
Imp
Impulsivity
P-ach
Poor achievement
Hyp
Hyperactivity
Emot
Emotional problems
Und
Underactivity
Peer
Poor peer relations
Non
Noncompliance
Fam
Family interaction problems
Att-g
Attention-getting behaviour
These scores indicate that the five greatest areas of improvement (see graph 4.3), as
experienced by the mother after the implementation of the intervention programme, are:
— 72 —
Hyperactivity
-
21% improvement
Family interaction problems -
21% improvement
Underachievement
-
20% improvement
Impulsivity
-
19% improvement
Poor achievement
-
15% improvement
GRAPH 4.3:
A GRAPHIC REPRESENTATION OF THE SCORES WHERE THE MOTHER EXPERIENCED
THE GREATEST IMPROVEMENT BASED ON THE RESULTS OF THE
COPELAND
SYMPTOMS CHECKLIST
100%
Percentiles
80%
60%
40%
20%
0%
Hyp
Fam
Und
Imp
P-ach
Pre Test
39%
50%
33%
47%
48%
Post test
18%
29%
13%
28%
33%
Symptoms
These scores indicate the most significant areas of improvement experienced by the mother;
however, she reported an improvement in nearly all the areas covered by the Copeland
Symptoms Checklist – except for “immaturity” where a rise in the score was reported. These
areas will now be discussed.
Inattention (Inatt)
Mary’s mother reported that there was only a slight improvement in
distractibility and reported that she is still struggling to get Mary into a routine.
She still could not give her more than one task at a time.
Impulsivity (Imp)
Mary’s mother experienced her as much less impulsive in that she now thinks
before acting. For example when her hamster died, Mary didn’t immediately
say she wanted another one when her mother offered to buy one. Instead,
she thought about it and then said she wanted a guinea pig because it would
live longer.
Hyperactivity
(Hyp)
According to her mother, previously Mary would not sit still when the family
visited relatives of friends; now she only has to ask once and Mary will sit still
or co-operate with what she asks.
— 73 —
Underactivity
(Und)
On the checklist Mary’s mother indicated that her leadership abilities have
increased – she will now dare to lead and not only be happy to follow.
Noncompliance
(Non)
According to Mary’s mother improvement in this area is evident from the fact
that she is now able to communicate better with Mary. As a result tasks given
and chores expected by Mary’s mom now gets done most of the time.
Attention getting
behaviour
Mary’s mother reported that she doesn’t interrupt as frequently as before and
that she doesn’t ask as many questions.
(Att-get)
Immaturity
(Immat)
In the pre test, Mary’s mother indicated that no aspects of immaturity were
present. In the post test the score on immaturity increased (indicating an
increased prevalence of immaturity). This is due to Mary’s mother reporting
that Mary relates better to younger children and that she prefers to be around
them.
Poor achievement
(Ach)
In this section Mary’s mother reported improvement in the following areas:
•
She understands and/or remembers what people say more effectively.
•
She succeeds better in completing assignments.
•
She does not rush the completion of her schoolwork as much as
previously.
•
Her handwriting is not as “messy” or as “sloppy” as before.
Emotional
Difficulties (Emot)
Mary’s mother reported no change in the emotional difficulties section; she
indicated that Mary is still sometimes easily frustrated.
Poor peer
relations (Peer)
An improvement was indicated in Mary’s ability to follow rules of games and
social interactions.
Family interaction
problems (Fam)
This area showed the following improvement:
•
Frequency of family conflict.
•
Unpleasantness at social gatherings.
•
Unpleasantness of meals.
•
Arguments between parents and child over responsibilities and chores.
•
Family stress resulting from the child’s social and academic problems.
Mary’s teacher also completed the Copeland Symptoms Checklist as a pre test.
On a
request that she completes it as a post test as well, she reported that there was no change.
She confirmed this after examining the results of the pre test. The results from the checklist
she completed follow in table 4.1.
TABLE 4.2:
SCORES FROM THE COPELAND SYMPTOMS CHECKLIST (PRE TEST) COMPLETED
BY
MARY’S TEACHER
Inatt
Imp
Hyp
Und
Non
Att-get
Immat
Ach
Emot
Peer
Fam
71%
63%
39%
47%
20%
22%
25%
52%
17%
11%
n.a.
— 74 —
These scores indicate that the five greatest concerns of the teacher, before commencement,
and after termination of therapy were:
Inattention
-
71%
Impulsivity
-
63%
Poor achievement
-
52%
Underactivity
-
47%
Hyperactivity
-
39%
From the above scores it would appear that a significant improvement in the home
environment could be noticed.
This improvement could be the result of many different
factors, or a combination of factors such as the therapeutic intervention (CCT), the
introduction of the board game, or focused attention by the parents on Mary’s attention
difficulties.
However, no marked improvement was evident in the school/classroom
environment. This may be attributed to the fact that the intervention programme did not
extend to the school. At the time the intervention programme was initiated, the parents did
not feel comfortable with medication and wanted to explore other avenues first. As a result
the intervention was strongly family-focused.
The therapeutic situations and the times when the board game was played at home were
furthermore
characterized as one-on-one, whereas, the school environment only
incorporates group contexts. The content applied in the different settings also differs in the
sense that the school makes use of academic content, whereas therapy and the board game
are based on a “fun-approach”.
The Copeland Symptoms Checklist is an instrument based upon the subjective opinions of
those completing it. As a result, it is possible that the mother manipulated the results of the
post test in an attempt not to disappoint the researcher or to give the “correct” answers. She
may also have felt that her neglecting to report in a positive manner would reflect negatively
on her own efforts and abilities. Finally, the mother’s scores relating specifically to academic
achievement cannot be regarded as objective or trustworthy, as she is not involved in the
classroom. Moreover, at the time when the questionnaire was completed Mary had not yet
received her latest report card, so the parents may have been under the false impression
that an improvement did take place in the academic system.
After reflecting on the above results, it also becomes important to acknowledge that it may be
unrealistic to expect of parents to perform CCT – even in the form of a board game. The
game may be simple to understand and to play, but the dynamics of a therapeutic situation
often are not. The mother may have progressed too rapidly between the different cards; she
— 75 —
may have been unaware of certain signals Mary sent out to indicate that she was not ready
to move on. Noticing and addressing these very subtle nuances emerging in a therapeutic
environment often plays a very important part in the success of therapy – specifically in CCT.
4.4.2
QUALITATIVE INSIGHTS
From the data analysis conducted on the qualitative data (interviews, observations and
feedback regarding the process)43, it would appear that the main contributing factor from this
study would be the positive effect the combination of CCT and parent guidance had – in this
instance through the use of the board game as parent guidance strategy. Therefore, the
main cluster emerging from the study is: combining CCT with parent guidance using a board
game. Secondary to this cluster, five qualitative insights emerged:
ª
Increased ability to distinguish between relevant versus irrelevant information.
ª
Increase in organizational thought in the therapeutic situation and at home.
ª
Improved communication resulting in improved skills to maintain discipline.
ª
Improved interaction among family members.
ª
Transfer of skills to the mother.
4.4.2.1 Ability to distinguish between relevant versus irrelevant information
In my observations of Mary it was evident to me, right from the start, that Mary experienced
great difficulty in withholding attention selectively from both external and internal distractions
(107)44:
“She gave me very long commands and often ‘lost her place’ in the giving of
commands”.
“…but she struggles a lot in giving commands and in organizing her thoughts”
[Evaluation and reflection, CCT session 3; 10 May 2006].
In session 4 Mary admitted for the first time that she saw (irrelevant) pictures, like faces or
animals when looking at the shapes (109):
“In her next turn, her attention shifted again and when I asked her about it, she
showed me a “face” that she could distinguish from the shapes on the table, she then
added that she could also distinguish the face of a dog. This was the first time she
43
44
Compare chapter 1 sections 6.2 and 6.4
Refers to page number contained in Appendix C and/or D. Appendix C and D contains the field notes of the
therapeutic sessions and the transcribed interview with the mother respectively.
— 76 —
admitted that she was distracted by irrelevant information” [Significant information
from the session, CCT session 4; 15 May 2006].
This happened again in session 5 (110):
“…the pictures and objects around us distracted her and she would often refer to one
of them and try to start a discussion on it and then use it as a model of what
command she gave me to build” [Evaluation and reflection, CCT session 5; 17 May
2006].
Mary’s mother also reported that Mary was sensitive towards distractions (118):
“But she was really aware that, of the fact that sometimes, some things might steal
her attention” [Interview with the mother; 14 June 2006].
It also happened that she would start talking about something else and I had to direct her
attention back to the session. From session 3 through to session 7 it was clear that Mary’s
attention was distracted by her own (irrelevant) thoughts. She would start to give a command
and then it would seem as though she lost her own place while talking, to the extent that it
became impossible to follow her commands (107-111). In those early stages of therapy
Mary was seemingly unable to direct her attention away from these irrelevant distractions, it
appeared that she was unaware of them.
Later on in our sessions Mary started to grasp the distinction – that certain objects or
information was irrelevant to the command I gave her – when in session 7, after I gave her a
command, she immediately removed the irrelevant shapes and started to work only with
those that were relevant to the command, I gave (111):
“M took away shapes she didn’t need to execute her command” [Evaluation and
reflection, CCT session 7; 24 May 2006].
Another occurrence worth mentioning was in session 11 – during which Mary was again
giving her long commands – when she suddenly interrupted herself and said that her
command doesn’t make sense and that she would start over (116):
“A breakthrough however came when she was giving one of her very long commands
again that do not make sense but realized it and stopped to tell me that it doesn’t
make sense and that she will start over” [Evaluation and reflection, CCT session 11; 7
June 2006].
— 77 —
This illustrated that she was thinking about her own thinking and that she was starting to
realize that it could also be irrelevant and distract her from her task. The same principles are
also facilitated through the board game (as mentioned in Chapter 345) and may indicate the
influence of the reciprocal process (CCT ↔ home) of reinforcing the principles of CCT at
home.
Mary’s mother also experienced an improvement with regard to Mary’s distractibility (118):
“I’m still having trouble asking her two things at the same time and then she’ll only do
the one. But she’s aware of, you asked me two things, what was the other thing? Ya,
she’s aware of that” [Interview with the mother; 14 June 2006].
When we terminated46 therapy Mary was able to recognize when she was distracted by
irrelevant information. She was aware of what it was that distracted her attention and she did
her best to work around it (116).
“Mary told me that she saw faces in the shapes and that it stole her concentration”
[Evaluation and reflection, CCT session 14; 19 June 2006].
4.4.2.2 Increase in organizational thought in the therapeutic situation and at home
As mentioned previously Mary’s thoughts would often appear to be elsewhere during the
therapeutic sessions. Sometimes she would start to speak and would then just stare (107):
“She often sat and stared” [Evaluation and reflection, CCT session 3; 10 May 2006].
On other occasions Mary would start referring to a square and would then switch to a
rectangle, for example (108):
“In giving commands she sometimes confuses shapes. One minute she will say
square and the next minute it will be a rectangle (meaning square)” [Evaluation and
reflection, CCT session 4; 15 May 2006].
In session 7 Mary and I decided on a couple of rules that we would apply in our sessions but
also in our classrooms (111):
45
46
Compare chapter 3 section 3.6.3.1 to 3.6.3.3 where the link between CCT and the board game is discussed.
Therapy was first terminated only with regard to the research and did continue without being recorded. It
was, however, terminated completely soon after as the intervention needed to be redirected towards the
inclusion of medication.
— 78 —
“No touching of the shapes while giving a command or reflecting on the other
person’s execution of a command”.
“Tell the other person when you see other pictures, either in the room or in the
shapes lying on the table in front of you. We will do this as these pictures “steal” our
concentration and it is not important (or relevant) while we are busy with our session”.
“We will make eye contact while receiving commands as this is the best way to
maintain focus and concentration” [Orientation, CCT session 7; 24 May 2006].
These rules would be there to help us focus our thoughts and our attention. Mary really took
them to heart and in the following sessions she applied them all the time (112; 113; 114):
“We concentrated a lot on placing our hands on the table while speaking as M
remembered it all the time” [Evaluation and reflection, CCT session 8; 29 May 2006].
“She was especially attentive towards all the “rules” we incorporated in previous
sessions and often reminded me when I neglected to apply some of them”
[Evaluation and reflection, CCT session 9; 31 May 2006].
“Mary concentrated well and kept her hands still while speaking” [Evaluation and
reflection, CCT session 10; 5 June 2006].
This seemed to play a significant role in helping her organize her thoughts, as she was now
aware of what she needed to do to keep herself focused. A contribution to the therapeutic
process occurred when the mother agreed to try to implement the rules at home as well. In
this instance the game as a parent guidance tool (and a means to strengthen the hands of
the therapist) appear to have a positive impact (112):
“Mom and I discussed the “rules” M and I implemented in our sessions and she
agreed to try to implement them as well” [Discussion with mom; 30 May 2006].
The mother later reported how she implemented one of the rules that she found useful (118):
“Like I had to call her on her name and say Mary look me in the eye, look at my eyes
for her to know that I’m now serious or for her to know that I, I this might, she might
not do what I’m asking” [Interview with the mother; 14 June 2006].
It would thus appear that while Mary was previously unaware of her attention being diverted
by irrelevant information, she is able to apply certain skills (through issues addressed in
— 79 —
therapeutic session and by her mother) that now enable her to organize her thoughts more
productively.
4.4.2.3 Improved communication resulting in improved skills to maintain discipline
Mary’s mother reported that the board game taught her that she should make Mary aware of
her surroundings, but that she should also be aware of her own surroundings (121).
“I must make Mary aware and I must also be aware of my surroundings” [Interview
with the mother; 14 June 2006].
The mother is of the opinion that she was not aware of this before she started playing the
game with Mary, and indicated that she implements the following strategies, (which she, in
her opinion, derived from playing the board game), in her communication with Mary:
•
She puts down everything when speaking to her daughter (120):
“I should mmh, put down, I should not have any other actions like speaking on the
phone” [Interview with the mother; 14 June 2006].
•
When she is speaking to Mary, she regards her as the only person around to speak
to (120/121).
“Mmh, now I know that um … I should, when I’m speaking to Mary I should speak to
her as if I’m speaking to her alone”.
“…and if I speak to Mary I must speak to her as if I’m speaking to Mary and nothing
else is important only me and Mary and the issue that we are speaking about”
[Interview with the mother; 14 June 2006].
•
She doesn’t jump from one topic to another while speaking to Mary, but finishes one
topic and then starts with another (121).
“You shouldn’t change topics inside a topic, I should finish a topic and then go on to
the next topic …” [Interview with the mother; 14 June 2006].
•
She doesn’t give Mary more than two tasks at the same time because she now
knows that it will be too much for her to take in (121).
— 80 —
“…and I shouldn’t like task Mary with more than two because I know she won’t be
able to handle more than two tasks …” [Interview with the mother; 14 June 2006].
•
Where previously she would give Mary many tasks, only to find later that they have
not been completed, she now gives a task and tells Mary to come tell her once it is
done (121).
“Even in the home situation, she is doing the dishes for me. And I would ask her
clean your room Mary and I would tell her something like all your shoes, put them in
your cupboard and call me when you are done and she does it” [Interview with the
mother; 14 June 2006].
•
She now only needs to look at Mary or speak to her once during a social visit to get
her to listen and co-operate whereas this was not the case previously (123).
“…now … I can just look at her and she knows to sit down or just ask her once
‘please behave yourself”’ [Interview with the mother; 14 June 2006].
Through the implementation of the board game a path was opened for parent guidance in a
facilitative fashion. The researcher was enabled to utilize the board game as a reference
when explaining certain concepts or issues pertaining to ADHD. By using the information
from the parent guidance session, Mary’s mother was able to develop ways of
communicating more pro-actively with her child.
This resulted in easing the process of
getting Mary to complete tasks and chores and it also enabled her to relate to Mary in a
“friendlier” way when she needed to discipline her. The improvement experienced by the
mother highlights the possible advantages of coupling CCT with parent guidance. From this
data it is, however, not clear whether including the principles of CCT in the board game
made a significant difference, as the techniques Mary’s mother now implements does not
have a direct correlation with that of CCT.
In this regard the value of the board game was restricted to being a space to experiment –
the mother could practise the skills discussed in parent guidance while playing the game.
This also indicates that the game does not need to rest on CCT principles as the aforementioned skills can probably be practiced using a generic game as well.
— 81 —
4.4.2.4 Improved interaction among family members
At the start of therapeutic intervention Mary did not have a very good relationship with her
brother. During the implementation of the game however, Mary invited her brother to play
the game with her (117).
“…even want her brother to play with” [Interview with the mother; 14 June 2006].
Their mother experienced this as a very positive sign and she is of the opinion that the
introduction of the board game had a positive and “bonding” effect on their relationship. She
indicated that while they had previously done things together as mother and daughter, the
board game meant even more to Mary because it was aimed at improving her concentration
– her development (122).
“Because suddenly she sees that we are doing something that is important to
…mmh…her development. And we do something together as mommy and girly
because we do a lot of other things together but it’s just, the game teaches you like I
said, so when she sees that this is something that she enjoys and I enjoy as well,
she likes it. That is why she likes the game, it keeps me and her focused on the
same thing” [Interview with the mother; 14 June 2006].
The board game created the opportunity for family interaction and also strengthened
relationships within the family. It appears to have added to the family’s cohesion and sense
of home (117).
“…even reminded you its time to play, even want her brother to play. My cousin
visited for a few days, for a few days she involved my cousin…” [Interview with the
mother; 14 June 2006].
Together with the influence of parent guidance, the increased time spent together and
focusing on the problem seems to constitute the primary contribution of the game. The fact
that different members of Mary’s family made time to play the game that was intended to
help her, appears to have a positive influence on Mary and this influence may have affected
their relationships positively.
— 82 —
4.4.2.5 Transfer of skills to the mother
Through combining parent guidance with the implementation of the game, Mary’s mother
acquired skills or strategies to apply when handling her child. These strategies appeared to
make her feel more competent as a parent. She even attempted to share skills with relatives
whose children also have an attention problem (120-121).
“I explained to my cousin how to handle her child, I think I got some lessons from
the game because I wasn’t aware of this but the game really helped me. I could
show her and tell her this is what I do with Mary this is what the game has showed
me that um I must make Mary aware and I must also be aware of my
surroundings…” [Interview with the mother; 14 June 2006].
Even though Mary’s mother attributes her newly acquired skills to the game, it may have
been that it only created the opportunity for her to become aware of how she could
implement the skills.
As mentioned earlier, these skills were facilitated through parent
guidance. By implementing it while playing the game – but more importantly, in everyday life
– she realised that it would not only equip her to cope better with Mary, but also help Mary to
cope better (121).
“…when I’m speaking to Mary I should speak to her as if I’m speaking to her alone”
[Interview with the mother; 14 June 2006].
“I must make Mary aware and I must also be aware of my surroundings” [Interview
with the mother; 14 June 2006].
Some of the principles included in the game did seem to have a positive impact on the
mothers’ own directing of attention. She reported that the game taught her to focus on what
she is busy with because she felt for her to help Mary focus, she herself also had to be
focused (122/121).
“So the game is great in the fact that it keeps you focused on the game, especially
with the cards, especially the colour cards, absolutely I love that, where you name the
colour but not the name of the colour, its like, it keeps me focused” [Interview with the
mother; 14 June 2006].
“…this is what the game taught me that I should be focused as well because I know
that for me to focus Mary will focus” [Interview with the mother; 14 June 2006].
— 83 —
Thus, the qualitative insights revealed that using a board game based on the principles of
CCT does not necessarily reinforce the afore-mentioned principles. A board game may
however be useful when used to practise skills facilitated in parent guidance. The primary
factor, however, is the positive influence experienced by the family as a result of including
parent guidance in the intervention process and – through the board game – creating
opportunities for the family to spend more time and focused attention on the problem.
4.5
CONCLUSION: INTEGRATING QUANTITATIVE AND QUALITATIVE RESULTS
The pre tests suggested that Mary displayed a fear of admitting that she had attention
problems – probably stemming from her fear of failure. It also emerged from the CCB that
Mary was sensitive to both internal and external distractions. Her family and peer relations
as well as her academic performance were affected negatively.
After the implementation of the intervention programme, it became apparent from the
observations of both the researcher and the mother, that Mary exhibited an improved ability
to distinguish between relevant and irrelevant stimuli in therapeutic sessions and at home.
The results from the Copeland Symptoms Checklist completed by the mother supports the
aforementioned claims.
These were, however, one-on-one situations, which cannot be
compared to a classroom situation. Even though the CCB profile indicates a significant
improvement in Mary’s ability to cope when faced with new tasks, she is still sensitive
towards external and internal distractions. Mary’s teacher also reported that she did not
notice any change in Mary with regard to her ability to withhold attention selectively. As
mentioned earlier, the fact that the intervention programme did not include the school, and
medication was not included in the programme may have made a substantial contribution to
the absence of improvement in the academic environment. The fact that the mother is not a
trained therapist and may have, as a result, missed important therapeutic information vital to
the success of CCT, could further have contributed to the principles of CCT not permeating
to the school environment.
Combining CCT with parent guidance and providing opportunities for the mother to
implement the skills facilitated in parent guidance seems to support the results of the
Copeland Symptoms Checklist that family relations improved. This improvement included
communication and interaction within the family system.
The insights presented in this chapter seem to support the combination of CCT with parent
guidance. It even indicates instances where a board game may be of value, but caution
should be taken when that board game is based on the principles of CCT. The inclusion of
— 84 —
these principles transforms the home-environment into a therapy room where the therapist is
not present. In such a therapy room valuable therapeutic moments may be lost; when the
therapy is not done in the correct way, or when clues are not interpreted correctly, it may
even be detrimental to the child’s selective attention abilities.
These findings suggest that the principles of CCT did not permeate to other systems. The
reasons were, however, not explored in the study.
---oOo---
— 85 —
CHAPTER 5
CONCLUSIONS AND RECOMMENDATIONS
5.1
INTRODUCTION
This chapter contains a summary of the research results, as presented in chapter 4, and are
integrated with relevant literature.
The researcher will attempt to answer the questions
guiding this study, and the limitations and contributions of the study are discussed.
Recommendations regarding the use of the board game for further research and for use in
practice are made.
5.2
SUMMARY OF THE RESULTS WITH REFERENCE TO RELEVANT LITERATURE
The combination of qualitative and quantitative data gathered in the study yielded various
insights regarding the use of a board game to reinforce CCT in the home environment of a
child with ADHD.
From the qualitative reports it transpired that Mary’s ability to distinguish between relevant
and irrelevant information improved. During therapeutic sessions and at home, she became
aware of times when her attention was distracted by both external and internal distractions.
The results from the CCB post-test also appeared to give an indication that Mary was aware
of being sensitive to particularly internal distractions. However, this apparent awareness
does not negate that her sensitivity towards both internal and external distractions – as
measured on the post-test – remains significant. The CCB profiles suggest deterioration in
Mary’s profile measured after the intervention programme – combining CCT with parent
guidance and the use of a board game based on the principles of CCT. Literature supports
the fact that – although effective in treating specific problems, behaviour therapy and parent
guidance are not effective in the treatment of ADHD when used in isolation (Wenar & Kerig,
2000:130-131). It appears as though multiple approaches (i.e., therapy coupled with
medication and parent guidance) is necessary to address ADHD with success: in certain
centres a child with ADHD will not benefit optimally from therapy without medication and
medication will not have the best possible effect without the parents’ understanding of ADHD
(by means of therapy) (McGuire & McGuire, 2001:67-68; Wenar & Kerig, 2000:129-130;
Green, 1995:80-81).
— 86 —
The positive contribution of combining CCT and parent guidance became apparent. Through
the facilitation of parent guidance, Mary’s mother began to acquire skills, which improved her
communication with Mary a great deal. In this regard, I concur with Sears and Thompson
(1998:164) that communication, and more specifically improved communication between the
different micro systems influenced by ADHD, may well form the heart of the process of
coping with ADHD.
In this study the improvement in communication appeared to have
emerged from the opportunity the mother had to practically experience what was facilitated in
the parent guidance sessions, while playing the game with Mary – note that the contribution
was in playing together and implementing certain skills, not in using the principles of CCT.
The improvement first began to surface when Mary’s mother realised that she should pay
attention to those aspects that may have appeared insignificant to her in the past – such as
making eye contact or ensuring that she has Mary’s attention before she gives her a task.
These are all elements that provide structure to communication, enabling the mother to make
sure that Mary understood what is expected of her. Implementing this type of structure can
be formidable for some parents (McGuire & McGuire, 2001:74). In the case of Mary and her
mother, this adjustment led her to complete more of the tasks her mother gave her, but it
also fostered a more understanding attitude in Mary’s mother. Consequently, the mother
experienced herself as more competent with regard to communicating with Mary in general,
but more specifically in maintaining discipline (Goldenburg & Goldenburg, 2000:282).
Goldenburg and Goldenburg (2000:280) are of the opinion that parents who are taught
specific skills, will not only apply those skills to solve the specific problem that they want to
address, but will also use the skills to handle other existing problems or ones that occur in
the future or with other children. Mary’s mother realized that the skills we discussed in
parent guidance, which she applied when playing the game with Mary, had wider applicability
and she was able to use it in other contexts – such as in disciplining Mary and
communicating with her. She also became aware of what she as a mother could do to help
Mary cope better with symptoms of ADHD; she even attempted to invest in the lives of family
members with children experiencing similar problems (McGuire & McGuire, 2001:72).
The relationships in Mary’s family were reinforced by the fact that the family felt the board
game created opportunities for interaction. These special dates that parents and children
spend together do facilitate a deeper bonding and stronger rapport with their child (McGuire
& McGuire, 2001:154). Time spent exclusively on the intervention (which, evidently in this
case does not need to include principles of CCT at home) may also lead to more
commitment to and involvement in therapy and to significantly greater results (McGuire &
McGuire, 2001:154). Mary was very excited about the game and invited different members
— 87 —
of her family to play it with her. She even invited her brother with whom she did not have a
very good relationship prior to the implementation of the game. The board game appears to
have facilitated a bonding experience between brother and sister in particular.
Mary’s
mother is of the opinion that the fact that they spent time playing the game that was intended
to help Mary, meant a great deal to her. It appears to be the positive effect of interaction –
resulting from the opportunities the board game created for the family to spend time together
– that led to the improvement. The fact that the game is based on the principles of CCT,
which the mother attempted to reinforce, became peripheral. The same results may have
been observed if any other (ordinary) game was introduced – with the explicit aim of helping
Mary.
Finally, as a therapist, I experienced the effect of the game in many spheres of my interaction
with the family. I immediately noticed a significant improvement in Mary’s performance during
a CCT session when she spent time with a family member, playing the game the day before
the session. This again highlights the positive role of the increased interaction that occurred
in the family system. Both Mary and her mother were excited about the game and the fact
that it gave them a common purpose appears to have contributed to the improvement they
experienced in the home environment. This excitement – especially form the mother’s side –
should, however, be viewed in light of the fact that she did not want to use medication and
that she was desperate to find another workable solution. As a result, her reports regarding
the game may have been influenced by this fact and may not be a true reflection of her
experience.
It is difficult to estimate the impact of the game, as both CCT and parent guidance played a
significant role in the intervention process.
However, the deteriorated profiles serve as
sufficient information to caution against the reinforcement of CCT by parents. In the next
section a conclusion of the findings of the study will follow, summarising the afore-mentioned
insights.
5.3
CONCLUSIONS GLEANED FROM THE STUDY
This research aimed to study the impact a board game, as a parent guidance strategy, could
have on reinforcing CCT in the home environment of a child with ADHD. The findings of the
study indicate that the use of a board game based on the principles of CCT, when used by a
parent/parents with a child, may have a detrimental effect on the selective attention of that
child.
Because of the limited scope of the study, however, a direct causal relationship
between the two factors cannot necessarily be established. The data from the CCB and the
teacher-generated data in this study, however, is regarded as significant enough to indicate
— 88 —
some caution in terms of integrating CCT as part of parental intervention with a child with
ADHD.
However, the generic use of a board game seemed to have impacted positively in terms of
familial relationships and the confidence levels of the participants in the study.
This is
indicated by the observational and mother-generated data in the study.
Thus, the following may be reported:
ª
The communication within the family, as well as relationships among the family
members, seems to have improved as a result of increased time spent together,
focusing on the problem;
ª
Both Mary and her mother are now handling the symptoms of ADHD more
effectively in the home environment.
ª
Mary’s ability to selectively direct her attention when confronted with external and/or
internal distractions remains problematic and detrimental to her academic
performance. Her ability to attend to new tasks, however, seems to have improved.
ª
ADHD needs to be addressed on multiple levels.
The findings of this study thus suggest that a distinction needs to be made between the
board game (which made a positive contribution), and the principles of CCT, which the
parent had to reinforce in the home environment (which appear to have had a detrimental
effect).
In the next section this consideration will be carried over when answering the
research questions.
5.4
ADDRESSING THE RESEARCH QUESTIONS
5.4.1
PRIMARY RESEARCH QUESTION
•
How can a board game be used as a parent guidance strategy to reinforce
CCT in a child’s home environment?
The findings from the research seem to indicate that a board game can be used as a parent
guidance strategy, but not to reinforce CCT in the home environment. Using a board game,
which mirrored the therapeutic situation and allowed the mother and child to apply the same
principles of CCT dealt with in the therapeutic session, appears to have led to deterioration in
the child’s ability to selectively direct her attention.
However, the board game did offer the mother the opportunity to apply other skills –
facilitated through parent guidance – which helped her to handle her daughter’s symptoms
— 89 —
more positively.
These skills did not include those facilitated by CCT and were rather
general, relating to communication and discipline.
5.4.2
CRITICAL QUESTIONS
•
How can the constructs of CCT be accommodated in a board game for
children in the middle childhood phase?
As CCT is a relatively structured therapy, its constructs can successfully be accommodated
in a board game by:
ª
grouping it into three categories aiming to facilitate the acquisition of the cognitive
control “Field articulation”; listening skills; and paying closer attention to a task at
hand;
ª
and converting the principles of each category into instructions that can be
transferred onto cards47:
o
Bunny cards48: facilitate the acquisition of the cognitive control “Field
articulation” through the use of the names of colours (irrelevant) printed in a
different colour (relevant)
Bluegreenyellowred
o
Bear cards: aim to facilitate the improvement of paying attention to a task at
hand – as well as the acquisition of listening skills – by asking a child to
perform a task that is simple at first but later incorporates some emotions.
Sit, stand, put up your right hand
o
Butterfly cards: contain the same shapes, in the same colours, as those
used in CCT. Through the use of these shapes the cards aim to facilitate the
acquisition of the cognitive control field articulation.
47
48
Compare chapter 3 section 3.6.3 for a discussion of the cards.
Compare chapter 3 section 3.3.4 for a discussion of the content the cards facilitated.
— 90 —
ª
Using these cards on a board49 designed to facilitate the random use of the cards by
players. The literature indicate that children in the middle childhood phase can
identify with board games, as they are most comfortable with being less playful (i.e.
play therapy for young children) yet not as verbally expressive as therapy intended
for adolescents. The game was adapted to be suitable for children in the middle
childhood phase by:
•
o
keeping the board rectangular in shape like most board games;
o
using primary colours appealing to both genders;
o
and using an animal theme.
How can parents reinforce CCT in the home environment by using a board
game?
The findings from the research indicate that caution should be taken when attempting to use
parents to reinforce CCT at home. Whereas the principles of CCT were adapted in a board
game and an effort was made to ensure that the game is user-friendly and simple, it still
remains therapy. The mother is not trained to facilitate therapy and as a result may not have
been able to recognize important therapeutic moments arising during time spent playing the
game with Mary.
It may even be detrimental to attempt reinforcing CCT in the home
environment.
•
What effect does parental involvement have on the CCT process?
Qualitative insights indicate that parental involvement was an invaluable part of this study.
Involving the mother in the implementation of the game led to an improved relationship
between mother and daughter. The mother acquired skills during parent guidance which she
could apply in everyday life to improve the communication between herself and Mary,
resulting in improved discipline. The mother experienced an increase in confidence as a
result of her newly acquired skills and wanted to share these with others. By being involved
in the intervention process and making a conscious effort to apply the skills facilitated to her,
mutual understanding and appreciation developed between mother and daughter.
5.5
ADDRESSING THE ASSUMPTIONS
The first assumption was that an improvement might become evident in each of the
micro systems due to the intervention.
This assumption could not be proven by the findings, as an improvement was only visible in
one micro system, namely the family system.
49
With regard to the family system, the
Compare chapter 3 section 3.6.1 for a discussion of the board.
— 91 —
assumption was that the improvement would be the result of family members feeling
empowered due to better understanding of the child with ADHD, as well as a result of
becoming aware of positive traits associated with ADHD. This assumption was only proven
in part, as the improvement was to a large extent the result of a better understanding of the
child with ADHD, but could also be ascribed to improved communication and improved family
relationships.
In the second micro system, namely the school, an improvement could not be noticed. As a
result better behaviour in class and awareness amongst teachers concerning the positive
traits of ADHD are not evident. Data was not gathered regarding any effect on the third
micro system namely the peers, as the focus was on the other micro systems, and therefore
the assumption that the peers would appreciate the improvement in the social skills of the
child with ADHD – and accept the child as their friend – were not tested.
It should, however, be kept in mind that this assumption rested on another assumption: that
CCB would create an improvement in the symptoms of the child. This assumption was made
regardless of the fact that literature suggests a multi-faceted intervention (it came as a result
of the parents who participated in the study not feeling comfortable with the inclusion of
medication, therefore wanting to explore other avenues first).
With the inclusion of
medication and an increased effort to reinforce CCT in the school environment, the
assumption may prove to be more accurate.
The second assumption is that improved relationships between the different micro
systems may become apparent in the meso system.
The findings of the study indicate that the relationship between the parent and the child (as
two micro systems in the meso system) did indeed improve. The individuals in these two
micro systems now have more understanding and empathy for each other – yet this effect
could not be seen regarding to the other micro systems found in the meso system. The
assumption that the individuals in the systems would become more tolerant towards each
other and work together as a team, also only applies to the mother (and to other family
members) and the child. The relationship between the parents and the school in particular
was not affected in any way detectable in this study. This assumption was recorded as a byproduct of the study. Once again, it rested on the assumption that the parent would feel
more comfortable to approach the school.
This type of interaction was, however, not
facilitated by the research in any way.
— 92 —
The third group of assumptions bears relevance to the child with ADHD and the impact the
intervention – in particular the board game – would have on her. The assumptions were that:
•
A child will be empowered through the principles of the game
Through parent guidance and increased interaction and focus on the problem,
communication improved in Mary’s home environment. Consequently, Mary completed more
tasks her mother gave her and this may have led to the improvement in her confidence. The
principles of the game, however, did not seem to have any positive effect and as a result did
not establish any empowerment in Mary.
•
Children will receive positive feedback from other systems
The results do not specifically show instances where Mary received positive feedback from
other systems.
It is, however, implied in the fact that her mother began to adapt her
communication in such a way that Mary was able to be successful in reacting to this
communication. As a result she may have experienced this adaptation as positive feedback.
•
An improved relationship between parent and child will develop
This assumption was proved by the one of the most prominent findings of the study: the
mother reported a significant improvement in her relationship with her daughter.
5.6
LIMITATIONS OF THE STUDY
ª
The findings emerging from this study cannot by generalized because the data was
gathered from a single case study. As a result, the sample used in this case is not
representative of the total population of children with ADHD.
ª
As a result of the complexity of contributing factors, it is difficult to establish causal
relationships.
ª
This study lent itself to potential researcher bias, as the researcher had a vested
interest in the game succeeding.
An attempt was made to compensate by
discussing the research process and the interpretation of data during supervisory
discussions and by reflecting on each therapeutic session in order to gain
perspective on the session.
— 93 —
5.7
CONTRIBUTIONS OF THE STUDY
The introduction of the board game into the home environment led to improved family
relationships, discipline, parent empowerment and education. The use of the board game as
a parent guidance strategy provided the therapist with the opportunity to identify with the
family and work together in the process of managing attention problems. The board game
also became a mediator that linked the parents, the child and the therapist and this became
a common factor that could be used to understand, address and question aspects of ADHD
in a practical manner. Using the game as common ground also enabled the mother and the
researcher to “speak the same language” as words or terms used in the formal sessions
were communicated to the mother. She could then also use them – for example, mother and
therapist used the phrase “things stealing her attention”50. Parent guidance should, however,
not attempt to use the parent as a facilitator of CCT in the home environment, but should be
separated from formal CCT sessions between child and therapist.
The study contributes to the expansion of the knowledge base of Educational Psychology as
the effects of the board game constitute a new knowledge base. CCT has never before been
studied in the context of reinforcement through a board game. The interpretation of the
experience of the participants involved in the implementation of the board game brought to
light cautionary aspects surrounding the use of the principles of CCT in the home
environment. This knowledge will bring about a revisit to the area of applicability of the
game. Thus the potential of the game to be improved in future may be unlocked.
Because the board game serves as common ground between the therapist and parents, it
can be used in the practice of Educational Psychology to facilitate or enhance parent
guidance, to empower the parent and create opportunities for the family to increase – and
improve – their interaction. The board game should, however, be kept generic by not basing
it on the principles of CCT (instead the board game may rather be suitable for therapists to
use as a tool in order to enhance the efficacy of CCT, or to alternate in between CCT
sessions and the board game).
Finally, this study also indicates that active involvement from parents in an intervention
programme for ADHD has a positive effect. This appeared true from the fact that, even
though medication is needed for an optimal outcome, many areas of potential improvement
were still visible. Thus the mere involvement of parents already constitutes a step towards
coping with ADHD.
50
Compare Appendix D p xxiii.
— 94 —
5.8
RECOMMENDATIONS
5.8.1
FURTHER RESEARCH
The study offers a snapshot of the impact of introducing the board game in the home
environment of a family with a child with ADHD. Further research, allowing for a more
comprehensive study of the impact of a board game on the different micro systems, is
recommended. This research could include:
ª
Studies examining the nature of coupled parent guidance and CCT.
ª
Examination of the efficacy of using generic board games not based on the
principles of CCT as a parent guidance strategy.
ª
An investigation into parent-teacher relationships where a child with ADHD is
involved.
ª
A study that examines the possibility of allowing more than two players to play the
game.
ª
Studies investigating the use of the board game by therapists.
5.8.2
EDUCATIONAL PSYCHOLOGY PRACTICE
Using a board game (not based on CCT) as part of parent guidance, together with facilitating
CCT to children with ADHD, could make parents an active part of the intervention process –
facilitating their own insights and allowing them the freedom to acquire skills in their own
home, while still having the opportunity to discuss these with the therapist. This may have a
positive effect on the outcome of therapy as the skills (or “solutions”) will be the parent’s own
discoveries and may add to their being more committed to sustain the incorporation thereof,
once formal therapy has been terminated.
5.9
CONCLUSION
ADHD is a disorder affecting many children and parents worldwide – leaving many parents
desperate, frustrated and even hopeless. Nonetheless as a result of the high demands
placed on teachers, it however increasingly becomes the responsibility of the parents to
intervene and help their children with ADHD.
The findings from this study suggest that therapists can contribute by using parent guidance
parallel to CCT. As a result of acquiring certain skills that will assist them on their journey
with their child, parents may gain more confidence for their task. They have an important
— 95 —
role to play in the intervention process of a child with ADHD. Facilitating their role regarding
this seems to have a positive effect on the relationship between parent and child, as well as
in the family environment. Offering the opportunity for families to increase their interaction
(by playing a board game) may have a bonding effect on the family as a whole, fostering
more understanding attitudes.
From these findings it would thus appear that a significant part of coping with ADHD lies
within the home environment. Fostering more understanding and empathetic relationships –
by creating opportunities for interaction – appears to have had a positive effect on the family
context, even though the symptoms of ADHD remained problematic in other contexts.
---oOo---
— 96 —
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---oooOooo---
— 102 —
APPENDIX A:
COPELAND SYMPTOMS CHECKLIST
— 103 —
— 104 —
APPENDIX B:
SUPPORTING DOCUMENTS
— 105 —
— 106 —
APPENDIX C:
FIELD NOTES OF SIGNIFICANT CCT SESSIONS AND INTERACTIONS WITH THE PARENTS
Session 3 – 10/05/2006 (Wednesday)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The dimensions of relevance/irrelevance for this session are many shapes (circle, square,
triangle and rectangle) and the progression from one colour (blue) to many colours (blue and
yellow).
Material
Big Thick Blue Square
Big Thick Blue Rectangle
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Blue Triangle
Orientation
I referred to our previous session where we started with only two shapes and then added more
to sensitise her to the fact that our field of information would change again today. I informed her
that we will add a new colour today.
Evaluation and reflection
M was very tired and her concentration span was very short. She often sat and stare. She gave
me very long commands and often “lost her place” in the giving of the commands.
Significant info from the session
M doesn’t have too much trouble in executing commands but she struggles a lot in giving the
commands and in organizing her thoughts.
— 107 —
SESSION 4 – 15/05/2006 (MONDAY)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The dimensions of relevance/irrelevance for this session are the use of many shapes (circle,
square, triangle and rectangle) and the progression from one colour (blue) to many colours (blue
and yellow).
Material
Big Thick Blue Square
Big Thick Blue Rectangle
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Blue Triangle
Orientation
M and I discussed the last session when we were feeling so tired and we agreed that we would
use the same shapes as we did the last time because we didn’t get to build enough with it.
Evaluation and reflection
M struggled to give commands. It seems as if her thoughts get lost somewhere in the process
and I had trouble following her commands.
In giving commands she sometimes confuses
shapes. One minute she will say square and the next minute it will be a rectangle (meaning
square). She does very well following my commands and reflecting on my behaviour.
Significant info from the session
It is clear that she has an attention problem when confronted with her own thinking as well as
external stimuli.
— 108 —
She would often see pictures (e.g. a face of an animal) in the shapes on the table and I told her
that it wasn’t her fault but that she needed to share it with me because it is the same things that
happen in school. In her next turn, her attention shifted again and when I asked her about it,
she showed me a “face” that she could distinguish from the shapes on the table, she then added
that she could also distinguish the face of a dog. This was the first time she admitted that she
was distracted by irrelevant information.
She said she gives me difficult commands because she wants me to give her difficult commands
too. Probably due to success experience as she does well in executing commands!!
M and mom only played the game on Saturday this past week.
SESSION 5 – 17/05/2006 (WEDNESDAY)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The dimensions of relevance/irrelevance for this session are the use of many shapes (circle,
square, triangle and rectangle) and the progression from one colour (blue) to many colours (blue
and yellow).
Material
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Blue Triangle
Big Thick Blue Rectangle
Orientation
I introduced today’s session by telling M that we would be adding another shape.
— 109 —
Evaluation and reflection
M had trouble executing commands today. We talked about “thought thieves” – things around
us, or things we think about that steal our concentration. Again she was reluctant to admit that
there were things that distracted her but the pictures and objects around us distracted her and
she would often refer to one of them and try to start a discussion on it and then use it as a model
of what command she gave me to build.
Significant info from the session
M started to admit that her concentration was distracted but she wouldn’t say by what. I find this
reluctance very interesting. She is now at a point where she uses the “distractions” as ideas for
commands to give me and it’s possible that she is afraid if she tells me that they distract her, she
won’t be able to use them anymore and that will lead to “failure” in her eyes.
Mom and M played the game on Saturday.
SESSION 7 - 24/05/2006 (WEDNESDAY)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The dimensions of relevance/irrelevance for this session are the use of many shapes (circle,
square, triangle and rectangle) and the progression from one colour (blue) to many colours (blue
and yellow).
Material
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Blue Triangle
Big Thick Yellow Rectangle
Big Thick Blue Rectangle
Big Thick Yellow Triangle
— 110 —
Orientation
M and I looked at specific things that “stole” her concentration and decided to incorporate the
following:
•
No touching of the shapes while giving a command or reflecting on the other person’s
execution of a command.
•
Tell the other person when you see other pictures, either in the room or in the shapes
lying on the table in front of you.
We will do this as these pictures “steal” our
concentration and it is not important (or relevant) while we are busy with our session.
•
We will make eye contact while receiving commands as this is the best way to maintain
focus and concentration.
Evaluation and reflection
This seemed to be a worth-while exercise. I believe M understood better what I meant and we
now had something concrete – in the form of “don’ts” or “rules” to work with. M took away
shapes she didn’t need to execute her command.
Significant info from the session
We had a very good session and it can probably be attributed to the fact that M is starting to
grasp the concept of relevant vs. irrelevant.
M and mom played the game on Saturday.
SESSION 8 – 29/05/2006 (MONDAY)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The dimensions of relevance/irrelevance for this session are the use of many shapes (circle,
square, triangle and rectangle) and the progression from one colour (blue) to many colours (blue
and yellow).
— 111 —
Material
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Red Circle
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Red Square
Big Thick Blue Triangle
Big Thick Yellow Rectangle
Big Thick Blue Rectangle
Big Thick Yellow Triangle
Orientation
We started this session with a recap on the “rules” of the previous session.
Evaluation and reflection
We concentrated a lot on placing our hands on the table while speaking as M remembered it all
the time; she even reminded me when I sometimes forgot. This seemed to have a positive
effect.
Significant info from the session
M liked to remind me if I forgot to put my hands on the table. It seems as if success experiences
means a lot to her and contributes a great deal towards the success we are experiencing at the
moment.
30/05/06 – DISCUSSION WITH MOM
I had a discussion with mom and it came to light that she didn’t understand exactly what was
expected of her. I explained to her again that the game is intended as a parent guidance tool
that aims to reinforce the principals addressed in the therapy sessions. We discussed the
possibility of her implementing the game more often during the week and preferably on every
day that we do not have a formal therapy session. She mentioned that they would enjoy it if I
could add some more shapes to the game as they have now used all the shapes. Mom and I
discussed the “rules” M and I implemented in our sessions and she agreed to try to implement
them as well.
— 112 —
SESSION 9 – 31/05/2006 (WEDNESDAY)
I created an “add-on pack” for the board game consisting of more shapes. I sent this, together
with an explanation of the session content to mom to incorporate in the game.
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The dimensions of relevance/irrelevance for this session are the use of many shapes (circle,
square, triangle and rectangle) and the progression from one colour (blue) to many colours (blue
and yellow).
Material
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Red Circle
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Red Triangle
Big Thick Blue Triangle
Big Thick Yellow Rectangle
Big Thick Red Rectangle
Big Thick Blue Rectangle
Big Thick Yellow Triangle
Orientation
After a short informal discussion about both our well-being, we immediately started the session.
We both know what the therapy is about and no real orientation is needed.
Evaluation and reflection
We had a very good session. M paid attention from the word go. She was especially attentive
towards all the “rules” we incorporated in previous sessions and often reminded me when I
neglected to apply some of them. We were also able to stretch our session by 5 minutes.
— 113 —
Significant info from the session
The way she paid attention today was striking and a huge improvement on any previous
session; even the best ones. After the session I discovered that she played the game with her
aunt the previous day. This was the first time they implemented the game more than once in a
week and the day before our session. The effect is very positive and significant.
SESSION 10 – 05/06/2006
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The complexity of the field of information will be increased by moving the shapes. In previous
session they were located close together and will now be placed far apart. The dimensions of
relevance/irrelevance for this session are the use of many shapes (circle, square, triangle and
rectangle) and the progression from one colour (blue) to many colours (blue and yellow).
Material
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Blue Triangle
Big Thick Blue Rectangle
Orientation
I started today’s session by introducing a change in our “game”. I explained to M that we will be
putting the shapes far apart from each other on the table.
Evaluation and reflection
M complained of a tummy ache before the session. Despite this the session went very well.
Mary concentrated well and kept her hands still while speaking. After about 20 minutes she said
— 114 —
that her tummy was really sore. We each had one more turn and then stopped. She confused
the square with the rectangle once.
Significant info from the session
I thought it was a great breakthrough that M was able to concentrate even though she was
feeling sick. She also had a blocked nose. M mentioned that her maths teacher said she
concentrates better. They played the game on Friday and Saturday and the influence of the
game on CCT seems to be positive and it appears to have a sustaining effect.
SESSION 11 – 07/06/2006 (WEDNESDAY)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The complexity of the field of information will be increased by moving the shapes. In previous
session they were located close together and will now be placed far apart. The dimensions of
relevance/irrelevance for this session are the use of many shapes (circle, square, triangle and
rectangle) and the progression from one colour (blue) to many colours (blue and yellow).
Material
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Blue Rectangle
Big Thick Yellow Rectangle
Big Thick Blue Triangle
Big Thick Yellow Triangle
Orientation
Informal chatting.
— 115 —
Evaluation and reflection
MD wasted a lot of time by making her shapes fall down and then building them again. I don’t
think she felt like our session today. A breakthrough however came when she was giving one of
her very long commands again that do not make sense but realized it and stopped to tell me that
it doesn’t make sense and that she will start over.
Significant info from the session
It seems like she is starting to think about what she is saying.
SESSION 14 – 19/06/2006 (MONDAY)
Goals for the session
To develop the child’s capacity to direct attention selectively at complex fields and configurations
of information in terms of dimensions of relevance/irrelevance.
The complexity of the field of information will be increased by moving the shapes. In previous
session they were located close together and will now be placed far apart. The dimensions of
relevance/irrelevance for this session are the use of many shapes (circle, square, triangle and
rectangle) and the progression from one colour (blue) to many colours (blue and yellow).
Material
Big Thick Blue Square
Big Thick Yellow Square
Big Thick Red Triangle
Big Thick Blue Circle
Big Thick Yellow Circle
Big Thick Red Circle
Big Thick Blue Rectangle
Big Thick Yellow Rectangle
Big Thick Red Rectangle
Big Thick Blue Triangle
Big Thick Yellow Triangle
Evaluation and reflection
Good session. Mary maintained good concentration throughout the session. I think we can
terminate sessions for research purposes. Mary told me that she saw faces in the shapes and
that it stole her concentration.
— 116 —
APPENDIX D:
INTERVIEW WITH THE MOTHER (J) – 14/06/2006
H: How did you experience the process of implementing
the game?
J: It was very interesting because ... mh... Mary, she knew
the game before ... you guys showed us how it worked
... so, for her, mmh, she felt proud because she could
show us something that she knew and we didn’t know.
It was fun at first, actually it was fun throughout. Mmh ...
she ... she really did know how to play, she showed us
... mmh ... even reminded you its time to play, even want
her brother to play with. My cousin visited a few days,
for a few days she involved my cousin, very exited to
show somebody else how this worked and ... what
Improved family
relationships
amázed me actually was that when people asked her
what the game was about she, she would actually tell
them it was helping her to focus, it was helping her to be
aware of stuff that was stealing her attention, she really
knew what this was for.
Mmh ... people sometimes
talked to me about it, its gréát this child knows what this
is for. Mmh ... I’m so glad she paid attention to you
Mary knew that the game
was to help her – It was
NB to her.
Hestie when you explained this game to her and why,
you explained to her what was this about what it is for,
so she would explain to people it wasn’t like, something
that, ag some lady showed me this game to play I don’t
know what it is about, she really knew what it was for. It
really amazed me.
H: So she, she understood it, and what about you?
J: She was able to make me understand because you
explained to me ...mmh, mmh ... I grasped the concept
but I didn’t know what it was about. But when we got
— 142 —
home and then we sat down, she literally showed me
this is for this, the cards the bunnies the, the butterflies
and stuff and the shapes. She explained to me as we
went along so she was in a position to really take from
you and give it to me.
H: If you think about your, this game in your house, your
home environment, what would you say how did the
Principles of game in
process go in implementing the game?
home environment
J: Mmh ... Mary was constantly really aware of, of, of, things
stealing her attention, mh, but she still, I, I can’t, I don’t
know if she allows things to steal her attention or if she
wasn’t aware that she was still doing it. Like I had to call
her on her name and say Mary look me in the eye, look
at my eyes for her to know that I’m now serious or for her
Mom may be too hasty?
Impatient?
to know that I, I this might, she might not do what I’m
asking. Mmh, I had to constantly like say Mary look in
my eyes, look at me, look at me, you know. But she was
really aware that, of the fact that sometimes, some things
might steal her attention. So mmh I’m still having trouble
with routine, getting her into a routine.
I’m still really
…mmh… getting, I’m still having trouble asking her two
things at the same time and then she’ll only do the one.
But she’s aware of, you asked me two things, what was
the other thing? Ya, she’s aware of that.
H: What would you say the, would you say that any of the
principals of this game was playing into your daily life,
Mary felt she meant
something and that she
could contribute
your way of handling her, any of the things that you were
taught through this game?
— 143 —
J: I would say so, mmh … like the cards with the, the, the,
where you have written down the colours but you written
it down say like the yellow you written in the colour red,
mmh … ya, she would pay attention to detail a bit more,
at home. Because that card showed us that although
the word yellow is there, that yellow is written in red for
you to know, to see the red instead of the yellow. Ya,
she paid attention to detail at home … not as fast as I
would want her to, but she is. Mmh, the other day her
hamster died, I forgot to tell you, he died, Jerry. She
was so sad because Jerry died.
I was busy in the
kitchen, when she called Jerry he didn’t come out of his
house, and then she pulled me and wanted me to see
that Jerry doesn’t want to come out of his house, she
was scared, I know, I think she knew something was
wrong. And then she … and I was on my phone, and
my phone rang again and she kept saying “call Jerry,
call Jerry”, and then he didn’t come out and I looked at
the house, still on my phone, and I looked at the house
and then I “come on Jerry”, and I, and I tilt it like this and
here poor Jerry fell out of the house. I put this phone
down immediately and I was like, she was like shocked
and cried immediately and I was like “aah” and Jerry
was dead and he was lying there and she up and went
out of her room and I came and then after a while she
came to me and she said it’s not that I’m not sad and
that I hate Jerry but can I go watch cartoons now.
Mmh…she was like aware that this small something
died, Jerry was her friend and … it’s not that she’s not
sad or that she didn’t like Jerry, but I think its her way of
coping with the sudden thing of Jerry. Like
— 144 —
we had a funeral the day after that because it was late
when we discovered that Jerry was dead and it was like
this specific spot where we had to bury Jerry and the
dogs mustn’t come near to this spot … mmh, we had to
Aware of surroundings –
put this sand on Jerry and some little bit of ground and
organize thoughts
… two yellow flowers, but like it was detail and we had a
prayer for Jerry mmh … it was like she was really there
and then I wanted to know should we get another
hamster, she said “no mummy he will die again after two
years” because she knows they die after two years “he
will just die after two years again and then, and then I
will be sad again” so, e, for me its like she’s aware, this
is detail and she’s aware of this. She now wants a,a,a
guinea pig because they’re bigger and they live longer
and so for me it’s detail. She was very sad, for two
nights she didn’t sleep in her room. So I think this game
really, really had an impact on Mary.
H: If you think now about you and the game, did you learn
anything from the game that you could apply when
Improved communication
–
better
handling
of
discipline
handling Mary?
J: I did definitely. Mmh, now I know that um … I should,
when I’m speaking to Mary I should speak to her as if
I’m speaking to her alone. I should mmh, put down, I
Mom became aware of
areas that she could work
on that may enhance the
home environment
should not have any other actions like speaking on the
phone. She wanted to tell me something I should have
put the phone down and listen to her, I, I know this from
this game, it’s a very interesting game. My other cousin,
she’s a teacher, she visited the other day and Mary
showed her this game. Her child actually has the same,
I can’t diagnose the child but really. I got her interested
in this game and I explained to my cousin
— 145 —
how to handle her child, I think I got some lessons from
the game because I wasn’t aware of this but the game
Mom realized it is a team
really helped me. I could show her and tell her this is
effort
what I do with Mary this is what the game has showed
me that um I must make Mary aware and I must also be
Improved comm.,
improved discipl – Mary
aware of my surroundings and if I speak to Mary I must
had a better chance of
speak to her as if I’m speaking to Mary and nothing else
under-standing and doing
is important only me and Mary and the issue that we are
what was asked of her.
speaking about. You shouldn’t change topics inside a
topic, I should finish a topic and then go on to the next
topic and I shouldn’t like task Mary with more than two
One of Mom’s
contributions to helping
because I know she won’t be able to handle more than
two tasks, so this is what the game taught me that I
should be focused as well because I know that for me to
focus Mary will focus. And she was really interested in
the game. I showed her the game, how it worked, why it
is like this, even Mary could explain what it was for.
Really this game … I think … um … and she’s a teacher
and she also works with children in her class that is not
paying attention, she really was interested in this game.
H: So would you say that this game had an impact on the
home situation, not only on her concentration?
J: Even in the home situation, she is doing the dishes for
me. And I would ask her clean your room Mary and I
would tell her something like all your shoes, put them in
your cupboard and call me when you are done and she
does it. I understand better how to talk to her and she is
more aware of what I ask her to do.
H: Do you have any problems with the game or any
suggestions?
— 146 —
J: Mmh … if maybe more than two can play the game,
mmh… why I say so is that, then it’s more exciting to
see because if it’s only two that play its now she throw, I
then throw, its my turn then her turn.
If its like four
people or even three people, because we’re always
more than two people here at home so now if me and
Mary play the game or whoever and Mary play the
game, then the others do not play along, so if you can
include maybe her brother or her father.
H: That makes sense.
J: And that’s all that I’d change.
H: What would you say are possible strengths of this
game?
J: The game teaches you to, to, really focus on the game
we are busy with. You’ve got to be there, because Mary
Mom
and
Mary
understand each other
better
knows this game and she knows when you’re just
running through it, she knows that, and I don’t want to
give her the idea that I’m just doing this for the sake of
doing it. So the game is great in the fact that it keeps
you focused on the game, especially with the cards,
Helped mom be more
focused as well
especially the colour cards, absolutely I love that, where
you name the colour but not the name of the colour, its
like, it keeps me focused.
H: If you say you must really be there because she knows
when you’re just running through it, do you think that its
Mary feels there is hope
adding to your relationship?
and mom is prepared to
J: It does. Because suddenly she sees that we are doing
help
something that is important to her and important to …mh
… her development. And we do something together as
mommy and her girly because we do a lot of other
things together but it’s just, the game teaches
— 147 —
you like I said, so when she sees that this is something
Game creates an
that she enjoys and I as well enjoy, she likes it. That is
opportunity to do things
why she likes the game because it keeps me and her
together.
focused on the same thing.
H: And if you now think of before I introduced the game to
you, what would you say is a major difference now after
you started using the game? Is there anything that you
can mention?
J: There is. Like Mary, she is like heavily restless at times.
When we were somewhere like at somebody’s house or
so, previously, then you, she was like all over the place
sometimes and she did not like it you see so I had to call
her and say don’t do this, or do this, silly things. I had to
ask her a few times Mary please behave yourself. Now
Improved comm and
… I can just look at her and she knows to sit down or
discipline (improved
just ask her once “please behave yourself”.
social skills)
H: To what would you attribute this?
J: To her knowing that, I think it comes back to the game,
the game is teaching Mary to be aware of her
Increased awareness of
surroundings and own
thoughts
surroundings, to be aware of what she’s doing in real
life.
H: Is there anything else you would like to add?
J: No, I think that is everything.
H: Thank you very much for your time.
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APPENDIX E:
PERMISSION TO DO RESEARCH
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APPENDIX F:
INFORMED CONSENT
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APPENDIX G:
ETHICAL CLEARANCE
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