Play therapy and storytelling intervention on children's social skills with attention deficit-hyperactivity disorder

Abstract

BACKGROUND:

Attention deficit-hyperactivity disorder (ADHD) is a common neuro-behavioral disorder that negatively affects educational, relational, and occupational aspects of one's life. Although many children diagnosed with this disorder can benefit from taking medication, particularly for core symptoms, play therapy and storytelling can be seen as engaging, stimulating, and more compatible with children's developmental needs. The social skills of these children are as vital as other symptoms and can be better addressed with cognitive-based art therapy interventions. Because little research has been focused on the combination of play therapy and storytelling and the social interactions of children with ADHD are highly important in academic settings, this study aimed to determine the effects of this combination on children's social skills with ADHD.

MATERIALS AND METHODS:

This survey was a quasi-experimental study with a pre-test–post-test design and a control group. Participants were 7–11-year-old girls and boys with ADHD based on DSM-V referred to child and adolescent psychiatrists’ clinics. Selected children were randomly allocated into intervention and control groups. The intervention group received an individual combined intervention of play therapy and storytelling, whereas the control group did not receive any therapeutic intervention for social skills at that time and was on the waiting list. The research tool was the Social Skills Rating System (SSRS), and data were computer-analyzed using SPSS-20 and a couple of descriptive and analytic tests including ANCOVA.

RESULTS:

In this study, 30 children with ADHD were included. The combined intervention of play therapy and storytelling has had a significant effect on post-test results of ADHD patients in terms of social skills as well as all test subscales (P < 0/05). There was a significant improvement in the subscales of self-expression, self-control, responsibility, and cooperation (P < 0.05).

CONCLUSIONS:

Results show promise for combined play therapy and storytelling intervention to enhance the social skills of elementary school children diagnosed with ADHD.

Introduction

Attention deficit hyperactivity is one of the most prevalent disorders in children and adolescents.[1] According to recent statistics, this disorder is common in 3% to 7% of children.[1] In addition to three core symptoms of ADHD, hyperactivity, impulsivity, and excessive inattention,[2] there are some other problems, such as poor social skills.[3] Regarding healthy functioning, social skills are momentous achievements and many researchers have claimed that failures in peer relationships affect children's progress, inter-personal success, and happiness[4] Although there have been five evidence-based treatments for children with ADHD, based on American Psychological Association including medication or parenting, some other interventions such as play therapy have been claimed to be fruitful to reduce children's externalizing and internalizing behavioral problems.[1] Freer et al. (2011)[5] suggest that therapeutic medications, although successful at addressing problems concerning attention and concentration, may not influence higher-order cognitive deficits that these children exhibit. Not all children will benefit from medication.[6]

Children through art materials can naturally and spontaneously express their inner feelings and thoughts, discover their interests, and gain a sense of control over the environment[7] and deal with emotional stress[8] through playing. Play therapy is a designed intervention to meet children's developmental needs. Young children have limited ability to express their concerns meaningfully through words alone, whereas play therapy provides them with a non-verbal and concrete means of expression that also crosses language and cultural barriers.[9] Some play therapy research has supported the utilization of this approach to reduce behavioral problems demonstrated by children.[1] As an intervention, storytelling is designed to actively involve the child in the treatment process and motivate the child to be part of the solution.[10] Story and storytelling are simultaneously cognitive processes and products of cognition.[11] Indeed, narrative therapy allows the person to see the problem and think about it as something outside himself or herself and be actively engaged in the expression of difficult emotions such as worry, anger, and confusion effectively and in a non-confrontational manner.[12]

Little research has been focused on the combination of play therapy and storytelling for developmental disorders, particularly ADHD. On one hand, concrete materials in play, such as toys, crafts, clay, and other play-based experiences provided in play therapy, afford children an age-appropriate and emotionally safe means to express their difficult experiences.[13] On the other hand, children with ADHD fail in staying focused on subjects thoroughly. They often can pay attention to some degree; thus, stories can involve them and help them pay heed to the content of stories.[14] With the importance of their symptoms not yet grasped, children seem to struggle with consuming medication and listening to psychiatrists’ and psychologists’ suggestions. According to the authors’ clinical experiences and positive outcomes of play therapy and storytelling regarding disruptive behavioral problems of children with ADHD, which are all mentioned above, this research aims to combine these two fruitful interventions and determine the effectiveness of combined intervention of play therapy and storytelling on social skills of 7 to 11 years old children with ADHD in Isfahan.

Materials and Methods

Study design and setting

This study was a randomized pre-test–post-test experimental design (quasi-experimental design). The study was performed in Isfahan, Iran, at a child and adolescent out-patient psychiatry clinic. There were two groups, intervention and control. For each participant in the intervention group, 10 sessions of combined intervention of play therapy and storytelling (two sessions per week in 60 minute sessions) were held by a group consisting of a child psychiatrist, a clinical psychologist, and a trained art therapist. Major psychiatric disorders such as post-traumatic stress disorder, evidence or history of any medical conditions, neglect or abuse, borderline IQ or intellectual disability, taking medications that might affect children's social skills (for example, SSRIs), and not having the interest to cooperate all unmet the criteria.

Study participants and sampling

Thirty children between the ages of 7 and 11 with a verified diagnosis of ADHD using DSM-V criteria met the inclusion criteria. Patients who met the study criteria entered the study, and there were not any missing cases. They were assigned to one of the intervention or control groups through random blocks, each containing two members. The patients were randomly divided into each block using Excel Random Allocation Software, and then, each block was randomly allocated to one of the study groups with similar software. Parents were also actively involved in their children's therapy sessions and contributed greatly to encouragement, feedback, and rewards. Table 1 shows the content of play therapy and storytelling sessions. The participants in the control group were on the waiting list by researchers.

Table 1.

Content of play therapy and storytelling sessions in the intervention group

Session	The title of plays and stories	Description and goal of each session
1	Introduction and acquaintance	Children become familiar with each other, with the setting of the play, and therapist/building friendship and trust among children/developing conversational skills/practicing appropriate body posture in social relationships (self- expression)
2	Puppet show/Story of three friends	To depict informational material with greater comprehension/to increase verbal capacity (cooperation/responsibility)
3	Index cards with brief descriptions and labels/the story of Hussein’s space car	A more engaging play than reading brochures/expressing anger calmly (self-control/responsibility)
4	Dominos placed in a circle/finding the name of the story (story of a shy octopus and a kind fish)	Depict the influence of one action on others/increasing attention to the environment/increasing vocabulary repertoire/gaining comprehension and listening skills/overcoming loneliness and isolation (self-expression/self-control)
5	Three adolescents or family members and a therapist standing at the pinnacle of a triangle/the story of the red cape	Each participant has two pieces of yarn, one in each hand, and each piece of yarn connects the participant to the next person. Each one states a maladaptive thought and pulls the string to the right, which triggers the second person to state a corresponding unpleasant feeling resulting from the thought, which prompts the third person to name a corresponding maladaptive behavior: a maladaptive thinking process results in a spiral of a negative thought, feeling, and behavior (self-expression/self-control)
6	Lose the Bruise strategy/the duck’s wrong story	Participants are asked to hold both a pretended shield and a plastic sword using each shield or sword to defend and protect himself or herself from a negative self-statement/understanding and expressing different emotional states/gaining skills in verbally expressing emotions/decreasing disobedience/overcoming shyness (self-expression/responsibility)
7	Interactive metaphors and stories/the story of an angry cat	To illustrate adaptive thinking styles: a kind of role-playing can help children connect helpful and unhelpful statements to various feelings and situations/controlling anger/saying no to others politely (self-expression/self-control)
8	Index cards with photographs/the story of “I am no longer ashamed”	A non-verbal way to identify symptoms and issues each participant is experiencing/problem-solving skills/avoiding making fun of others/overcoming shyness and isolation (responsibility/self-control)
9	Psychoeducational material such as therapeutic stories with symptoms, adjustments, and coping strategies/the story of the little Sepehr and the dwarf man	Children can be engaged in a battle and say “run ADHD off my land” Accepting failure/coping with a rival victory (cooperation/self-control)
10	Painting/the closing ceremony	The child is asked to draw specific thoughts, feeling, and behavior that apply to her or his problem situation/familiarization with various social roles and the community’s expectations/developing communicational skills/reviewing past sessions and discussing story points (cooperation/responsibility)

Data collection tool and technique

In this research, the parents’ form of the Gresham and Elliott (1990) SSRS Questionnaire was used to evaluate children's social skills. This 55-item version of the grading system has two subscales of social skills and problematic behavior. The social skill subscale includes 40 items and assesses cooperation, assertiveness, responsibility, and self-control. The problematic behavior subscale includes 18 items and is dedicated to assessing hyperactivity, internal problems, and external problems. The scoring of this system is performed with a Likert scale from 0 to 3. Social skills range from 0 to 120 with a higher score indicating higher social skills and lower scores indicating poor social skills. The required time for filling out the questionnaire is 10 to 25 minutes. Jason has claimed the internal consistency coefficient based on SSRS total score ranging from 0.86 to 0.90 and long-term stability coefficients ranging from 0.32 to 0.72 for both parents’ ratings.[15] Based on the Van Horn et al.[16] examination, results showed high internal consistency and moderately high validity for both social skills and problematic behavior scales. In Shiraz, Iran, in the year 1377, Cronbach's alpha coefficient of the test was 0.82 in the parents’ form.[17] In another research by Shahim in the mentally retarded population, Cronbach's alpha reliability coefficient of the parent form was reported to be 0.82 in the field of social skills in general, which was comparable to the original scale (0.87).[18] The main structure of therapy sessions was considered based on the core components of the cognitive behavioral approach in the book “Blending Play Therapy with Cognitive Behavioral Therapy” by Athena A. Drewes,[19] yet some changes were made according to received information and children needs. The book ‘Parents’ for solving children's anxiety problems by Karbasi Amel and Arman (2010) was also used as a guide for children to start their stories.[20] Play therapy sessions were designed to increase cooperation, courage, responsibility, and self-control to develop social skills in children with ADHD. Demonstrative, role-playing, and participatory methods were used during the sessions. Also, to increase children's cooperation, dependency management techniques such as positive reinforcement, shaping, and so on were used. Data were computer-analyzed using SPSS-20 and a couple of descriptive and analytic tests including ANCOVA. The test was parametric; hence, mean descriptors and standard deviations were used to evaluate the descriptive findings and an analysis of covariance was used to evaluate the effectiveness of the intervention. Because of the small sample size, confounding variables did not justify. The primary outcome of this study was to assess and compare the efficacy of the intervention on the social skill of ADHD patients using the SSRS Questionnaire scale filled at baseline and the end of the training sessions. Other retrieved data included demographic characteristics including age and gender.

Ethical consideration

The protocol of this study was confirmed by the ethics committee of Islamic Azad University Khomeinishahr Branch with research project number 18821603932067. The authors maintained all the protocols before performing all the procedures engaged in this study involving human participants following the ethical standards of the research committee. Informed consent, voluntary participation, anonymity, and confidentiality were respected. The study protocol was primarily designed according to the ethical tenets of the Helsinki Declaration. Legal guardians of the included population were informed about the study protocol and re-assured regarding the confidentiality of personal information and that the results of the research will be published as statistical and general conclusions, not individual. In addition, after completing the research, if they wish, they can participate in a free consultation session to become aware of the results of the treatment intervention and individual results of the questionnaires before and after therapy, and they can be given the chance to express additional suggestions for improving the therapy process. Then parents were asked to fill out the written consent and signed written consent. The modified Declaration of Helsinki regulations were followed throughout the experiment. The trial was free of any commercial interference. Participants were excluded from the study if they were not interested in continuing to cooperate during therapy, the presence of other psychiatric disorders, and the absence of more than two sessions; however, there were no missing cases.

Results

Forty-four ADHD children were primarily assessed regarding their eligibility for participation in the study, among which 30 met the study criteria and were randomly allocated into two groups of the study (n = 15 for each group). None of the participants in the studied groups withdrew from the study. Finally, the current study was conducted on 30 children with ADHD. The mean age of all participants was 8.5 (1.72), and separately females were 36% and males were 64%, which are shown in Table 2 based on two study groups. The two study groups were statistically similar in terms of age (P value = 0.20) and gender distribution (P value = 0.37).

Table 2.

Demographic characteristics

Variables	Intervention group n=15	Control group n=15	P
Age (years)	8.6 (1.92)	8.4 (1.52)	0.20
Female/Male	6 (40%)/9 (60%)	5 (27%)/10 (73%)	0.37
Types of ADHD [n (%)]
Hyperactive/impulsive	5 (33%)	5 (33%)	>0.05
Inattentive	4 (26%)	3 (20%)	>0.05
Combined	6 (40%)	7 (47%)	>0.05

The mean (SD) of social skills and its subscales in the two studied groups at pre-test and post-test are presented in Table 3. In the intervention group, there was a significant improvement in the mean level of studied variables at post-test evaluation (P < 0.05). There was no significant difference between pre- and post-test in the control group (P > 0.05). Analysis of covariance indicated that after the intervention, there were significant changes for social skills (P < 0.001, 49%) and its subscales as follows: self-expression, 46%; self-control, 28%; responsibility, 37%; and cooperation, 30% (P < 0.05).

Table 3.

Mean differences in social skill scores before and after intervention

Variables	Social Skills (χ̅±SD)			Social Skill Subscales
				Self-expression (χ̅±SD)			Self-control (χ̅±SD)			Responsibility (χ̅±SD)			Cooperation (χ̅±SD)
	Pre-test	Post-test	P (within groups)	Pre-test	Post-test	P (within groups)	Pre-test	Post-test	P (within groups)	Pre-test	Post-test	P (within groups)	Pre-test	Post-test	P (within groups)
Intervention group (n=15)	59.06±18.37	73.42±15.88	<0.05	18.27±5.82	21.93±3.74	<0.05	12.53±4.86	16.07±4.80	<0.05	15.67±4.11	19.40±3.15	<0.05	12.60±5.57	16.13±5.89	<0.05
Control group (n=15)	58.4±21.53	57.2±19.26	>0.05	19.13±5.84	18.40±4.48	>0.05	12.07±5.58	12.13±5.65	>0.05	15.73±6.19	15.33±6.20	>0.05	11.47±6.94	11.33±5.76	>0.05
P (between groups)	<0.05			<0.05			<0.05			<0.05			<0.05

Discussion

This study aimed to evaluate the efficacy of combined play therapy and storytelling on the social skills of children who suffer from ADHD. As the demographic characteristics and baseline measurements were similar between the intervention and control groups, all the outcomes can be attributed to the intervention. Accordingly, the results showed that this intervention led to significant improvement in the social skills of children diagnosed with ADHD. Therefore, if kindergartens and schools set their educational lessons based on a scientific and workable plan and centralize games and stories, relational problems of children would better be solved, social capabilities would improve, and potential issues would emerge through such mediums earlier.

The reason leading us to design this study is that although children with ADHD attempt to forge relationships with peers, these attempts are often viewed as negative, immature, and intrusive owing to ineffective social skills, failure in social processing, and social cognition. These individuals are also likely to be unaware of their impaired social skills, which leads to difficulties maintaining peer relationships.[2] Problems with peer acceptance and interactions are common, and peer rejection predicts later global impairment, cigarette smoking, delinquency, and anxiety; hence, it seems important to address peer rejection to improve the long-term outcomes that these children will probably struggle with in the future.[3] Additionally, directive methods would not work for these children;[14,21] therefore, most studies in this field are focused on interventions such as play therapy and storytelling.

Children through playing find a good opportunity to interact, communicate effectively, take turns, and emulate behaviors that are rewarded by the coaches. The child gradually internalizes these new skills and more pleasant behaviors. By playing, children express their feelings more easily and develop new relationships, which increases their happiness and adaptability to the surrounding environment. This, in turn, reduces attention deficit/passivity problems and increases their internal capacities to adapt to the environment. Meanwhile, storytelling process actually changes the child's attention and would alter it from passive to active. Although they are actively telling their stories, they can express their emotions by attributing them to the story characters. It can be regulative and therapeutic when they find a non-threatening way to face their thoughts, fears, and emotions.

However, in reviewing the background, these studies just examined the positive effects of interventions on reducing behavioral symptoms and signs of ADHD and indicated to be efficient methods: applying just play therapy,[22,23,24,25] just storytelling,[6,14,26] and the combination of them.[27,28] Regarding these types of interventions, limited studies have been performed on the social skills of ADHD children. In a single-case study by Meany-Walen and Teeling (2016),[29] Adlerian play therapy made a decline in disruptive behavior and poor social skill of three participants, and the changes in desired behavior of participants were consistent. Ashori et al. (2019)[30] showed that play therapy improves social skills, cooperation, self-assertiveness, and self-control in pre-school children with ADHD. Ray et al. (2007)[1] assessed the efficacy of play therapy (16 individual 30 minute sessions) in 60 school-age children with ADHD on anxiety and withdrawal, and the results showed a statistically significant improvement. Hosseinnezhad et al. (2020)[31] showed that narrative therapy is more effective than anger management training in terms of increasing academic self-efficacy and social relations. Yati et al. (2017)[32] bore a close resemblance to our study, suggesting the efficacy of storytelling in play therapy in hospitalized pre-school children diagnosed with ADHD on a reduction in these children's anxiety levels.

Limitation and recommendation

Along with the strengths of this study such as novelty and placing a high value on the social skills of children with ADHD rather than just alleviating their symptoms, there are some limitations. First and foremost, we utilized convenient sampling; hence, random sampling should be used in the future. Moreover, a larger sample size is suggested and caution should be exercised in generalizing treatment outcomes of this research. Furthermore, we failed to follow up after intervention because of financial constraints; therefore, more regular follow-up programs should be considered. It is also suggested that a course of treatment should be held at school time and parenting skills be integrated with such kinds of interventions to make the whole process more effective.

Conclusion

In summary, ADHD symptoms hinder children's progress in many situations and aspects. As a prevalent and frustrating disorder, ADHD harms peer relationships because of the lack of positive inter-personal skills, empathy, or sociable manner as well as emotional regulation. Because play materials and stories are inseparable parts of children's lives and they are almost always accessible in clinics, schools, and houses and for clinicians, teachers, and even parents, they can be taken advantage of. Medications seem to be neither financially accessible nor enjoyable for children. However, playing and being engaged in stories are both financially affordable and stimulating. The implication of this study appears to be of paramount importance to the health care system, meaning that children often demonstrate their social behavior in peer groups, playing groups, kindergartens, and schools more clearly; hence, early diagnosis and preventive actions can be taken place at early ages. Our research can provide clinicians or elementary school teachers with a practical therapy sessions, precise content, and therapeutic treatment plan. We suggest to the academic spheres that applying both play therapy and storytelling to elementary school children with ADHD can pave the way for improving social skills and very early signs of poor social behavior. Additionally, employing a trained art therapist or child psychologist in schools, who can professionally observe children and create preventive action plans, would be of significance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Ethical approval

The protocol of this study was confirmed by the ethics committee of Islamic Azad University Khomeinishahr Branch with research project number 18821603932067.

Financial support and sponsorship

This research was a completely self-funded study by authors.

Conflicts of interest

There are no conflicts of interest.