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Play therapy and storytelling
intervention on children’s social skills
with attention deficit‑hyperactivity
disorder
Website:
www.jehp.net Afsaneh Karbasi Amel, Helia Rahnamaei1, Zeinab Hashemi2
DOI:
10.4103/jehp.jehp_1104_22
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
Department of Psychiatry,
subscales of self‑expression, self‑control, responsibility, and cooperation (P < 0.05).
Isfahan University of
Medical Sciences, Isfahan, CONCLUSIONS: Results show promise for combined play therapy and storytelling intervention to
Iran, 1Master of Child enhance the social skills of elementary school children diagnosed with ADHD.
and Adolescent Clinical Keywords:
Psychology of Kharazmi Attention deficit‑hyperactivity disorder, play therapy, social skills, storytelling
University, Clinical
Psychologist, Tehran, Iran,
2
Master of Counseling/
Islamic Azad University
Introduction impulsivity, and excessive inattention,[2]
of Khomeinishahr,
there are some other problems, such as
Khomeinishahr, Iran

Address for
A ttention deficit hyperactivity is one
of the most prevalent disorders in
children and adolescents.[1] According to
poor social skills. [3] Regarding healthy
functioning, social skills are momentous
achievements and many researchers have
correspondence: recent statistics, this disorder is common in claimed that failures in peer relationships
Dr. Helia Rahnamaei,
Master of Child and 3% to 7% of children.[1] In addition to three affect children’s progress, inter‑personal
Adolescent Clinical core symptoms of ADHD, hyperactivity, success, and happiness[4] Although there
Psychology of Kharazmi have been five evidence‑based treatments for
University, Clinical
This is an open access journal, and articles are
Psychologist, Tehran, Iran. distributed under the terms of the Creative Commons
E‑mail: helia.rahnamaei@ Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Karbasi Amel A,
ru.nl allows others to remix, tweak, and build upon the work Rahnamaei H, Hashemi Z. Play therapy and
non‑commercially, as long as appropriate credit is given and storytelling intervention on children's social skills
Received: 31‑07‑2022 with attention deficit-hyperactivity disorder. J Edu
the new creations are licensed under the identical terms.
Accepted: 06‑11‑2022 Health Promot 2023;12:317.
Published: 29-09-2023 For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

© 2023 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
 Karbasi Amel, et al.: Play therapy and storytelling for children with ADHD

children with ADHD, based on American Psychological on social skills of 7 to 11 years old children with ADHD
Association including medication or parenting, some in Isfahan.
other interventions such as play therapy have been
claimed to be fruitful to reduce children’s externalizing Materials and Methods
and internalizing behavioral problems. [1] Freer et al.
(2011)[5] suggest that therapeutic medications, although Study design and setting
successful at addressing problems concerning attention This study was a randomized pre‑test–post‑test
and concentration, may not influence higher‑order experimental design (quasi‑experimental design). The
cognitive deficits that these children exhibit. Not all study was performed in Isfahan, Iran, at a child and
children will benefit from medication.[6] adolescent out‑patient psychiatry clinic. There were two
groups, intervention and control. For each participant
Children through art materials can naturally and in the intervention group, 10 sessions of combined
spontaneously express their inner feelings and thoughts, intervention of play therapy and storytelling (two
discover their interests, and gain a sense of control sessions per week in 60 minute sessions) were held
over the environment [7] and deal with emotional by a group consisting of a child psychiatrist, a clinical
stress[8] through playing. Play therapy is a designed psychologist, and a trained art therapist. Major
intervention to meet children’s developmental needs. psychiatric disorders such as post‑traumatic stress
Young children have limited ability to express their disorder, evidence or history of any medical conditions,
concerns meaningfully through words alone, whereas neglect or abuse, borderline IQ or intellectual disability,
play therapy provides them with a non‑verbal and taking medications that might affect children’s social
concrete means of expression that also crosses language skills (for example, SSRIs), and not having the interest
and cultural barriers.[9] Some play therapy research has to cooperate all unmet the criteria.
supported the utilization of this approach to reduce
behavioral problems demonstrated by children.[1] As an Study participants and sampling
intervention, storytelling is designed to actively involve Thirty children between the ages of 7 and 11 with a
the child in the treatment process and motivate the child verified diagnosis of ADHD using DSM‑V criteria met
to be part of the solution.[10] Story and storytelling are the inclusion criteria. Patients who met the study criteria
simultaneously cognitive processes and products of entered the study, and there were not any missing cases.
cognition.[11] Indeed, narrative therapy allows the person They were assigned to one of the intervention or control
to see the problem and think about it as something groups through random blocks, each containing two
outside himself or herself and be actively engaged in the members. The patients were randomly divided into each
expression of difficult emotions such as worry, anger, block using Excel Random Allocation Software, and
and confusion effectively and in a non‑confrontational then, each block was randomly allocated to one of the
manner.[12] study groups with similar software. Parents were also
actively involved in their children’s therapy sessions
Little research has been focused on the combination and contributed greatly to encouragement, feedback,
of play therapy and storytelling for developmental and rewards. Table 1 shows the content of play therapy
disorders, particularly ADHD. On one hand, concrete and storytelling sessions. The participants in the control
materials in play, such as toys, crafts, clay, and other group were on the waiting list by researchers.
play‑based experiences provided in play therapy,
afford children an age‑appropriate and emotionally safe Data collection tool and technique
means to express their difficult experiences.[13] On the In this research, the parents’ form of the Gresham and
other hand, children with ADHD fail in staying focused Elliott (1990) SSRS Questionnaire was used to evaluate
on subjects thoroughly. They often can pay attention children’s social skills. This 55‑item version of the
to some degree; thus, stories can involve them and grading system has two subscales of social skills and
help them pay heed to the content of stories.[14] With problematic behavior. The social skill subscale includes
the importance of their symptoms not yet grasped, 40 items and assesses cooperation, assertiveness,
children seem to struggle with consuming medication responsibility, and self‑control. The problematic
and listening to psychiatrists’ and psychologists’ behavior subscale includes 18 items and is dedicated to
suggestions. According to the authors’ clinical assessing hyperactivity, internal problems, and external
experiences and positive outcomes of play therapy and problems. The scoring of this system is performed with
storytelling regarding disruptive behavioral problems a Likert scale from 0 to 3. Social skills range from 0 to
of children with ADHD, which are all mentioned 120 with a higher score indicating higher social skills
above, this research aims to combine these two fruitful and lower scores indicating poor social skills. The
interventions and determine the effectiveness of required time for filling out the questionnaire is 10 to
combined intervention of play therapy and storytelling 25 minutes. Jason has claimed the internal consistency
2 Journal of Education and Health Promotion | Volume 12 | September 2023
 Karbasi Amel, et al.: Play therapy and storytelling for children with ADHD

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 A more engaging play than reading brochures/expressing anger calmly
of Hussein’s space car (self‑control/responsibility)
4 Dominos placed in a circle/finding the name of the Depict the influence of one action on others/increasing attention to the
story (story of a shy octopus and a kind fish) 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 Each participant has two pieces of yarn, one in each hand, and each
standing at the pinnacle of a triangle/the story of the piece of yarn connects the participant to the next person. Each one states
red cape 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 To illustrate adaptive thinking styles: a kind of role‑playing can help children
cat 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 A non‑verbal way to identify symptoms and issues each participant
longer ashamed” is experiencing/problem‑solving skills/avoiding making fun of others/
overcoming shyness and isolation (responsibility/self‑control)
9 Psychoeducational material such as therapeutic stories Children can be engaged in a battle and say “run ADHD off my land”
with symptoms, adjustments, and coping strategies/the Accepting failure/coping with a rival victory (cooperation/self‑control)
story of the little Sepehr and the dwarf man
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)

coefficient based on SSRS total score ranging from 0.86 used as a guide for children to start their stories.[20] Play
to 0.90 and long‑term stability coefficients ranging from therapy sessions were designed to increase cooperation,
0.32 to 0.72 for both parents’ ratings.[15] Based on the Van courage, responsibility, and self‑control to develop
Horn et al.[16] examination, results showed high internal social skills in children with ADHD. Demonstrative,
consistency and moderately high validity for both social role‑playing, and participatory methods were used
skills and problematic behavior scales. In Shiraz, Iran, during the sessions. Also, to increase children’s
in the year 1377, Cronbach’s alpha coefficient of the test cooperation, dependency management techniques
was 0.82 in the parents’ form.[17] In another research such as positive reinforcement, shaping, and so on
by Shahim in the mentally retarded population, were used. Data were computer‑analyzed using
Cronbach’s alpha reliability coefficient of the parent SPSS‑20 and a couple of descriptive and analytic tests
form was reported to be 0.82 in the field of social including ANCOVA. The test was parametric; hence,
skills in general, which was comparable to the original mean descriptors and standard deviations were used
scale (0.87).[18] The main structure of therapy sessions to evaluate the descriptive findings and an analysis
was considered based on the core components of the of covariance was used to evaluate the effectiveness
cognitive behavioral approach in the book “Blending of the intervention. Because of the small sample size,
Play Therapy with Cognitive Behavioral Therapy” by confounding variables did not justify. The primary
Athena A. Drewes,[19] yet some changes were made outcome of this study was to assess and compare the
according to received information and children needs. efficacy of the intervention on the social skill of ADHD
The book ‘Parents’ for solving children’s anxiety patients using the SSRS Questionnaire scale filled at
problems by Karbasi Amel and Arman (2010) was also baseline and the end of the training sessions. Other
Journal of Education and Health Promotion | Volume 12 | September 2023 3
 Karbasi Amel, et al.: Play therapy and storytelling for children with ADHD

retrieved data included demographic characteristics Table 2: Demographic characteristics

including age and gender. Variables Intervention Control group P
group n=15 n=15
Ethical consideration Age (years) 8.6 (1.92) 8.4 (1.52) 0.20
The protocol of this study was confirmed by the ethics Female/Male 6 (40%)/9 (60%) 5 (27%)/10 (73%) 0.37
Types of ADHD [n (%)]
committee of Islamic Azad University Khomeinishahr
Hyperactive/impulsive 5 (33%) 5 (33%) >0.05
Branch with research project number 18821603932067.
Inattentive 4 (26%) 3 (20%) >0.05
The authors maintained all the protocols before
Combined 6 (40%) 7 (47%) >0.05
performing all the procedures engaged in this study
involving human participants following the ethical
standards of the research committee. Informed consent, group (P > 0.05). Analysis of covariance indicated that
voluntary participation, anonymity, and confidentiality after the intervention, there were significant changes for
were respected. The study protocol was primarily social skills (P < 0.001, 49%) and its subscales as follows:
designed according to the ethical tenets of the Helsinki self‑expression, 46%; self‑control, 28%; responsibility,
Declaration. Legal guardians of the included population 37%; and cooperation, 30% (P < 0.05).
were informed about the study protocol and re‑assured
regarding the confidentiality of personal information Discussion
and that the results of the research will be published
as statistical and general conclusions, not individual. This study aimed to evaluate the efficacy of combined
In addition, after completing the research, if they wish, play therapy and storytelling on the social skills of
they can participate in a free consultation session to children who suffer from ADHD. As the demographic
become aware of the results of the treatment intervention characteristics and baseline measurements were
and individual results of the questionnaires before similar between the intervention and control groups,
and after therapy, and they can be given the chance all the outcomes can be attributed to the intervention.
to express additional suggestions for improving the Accordingly, the results showed that this intervention led
therapy process. Then parents were asked to fill out to significant improvement in the social skills of children
the written consent and signed written consent. The diagnosed with ADHD. Therefore, if kindergartens and
modified Declaration of Helsinki regulations were schools set their educational lessons based on a scientific
followed throughout the experiment. The trial was and workable plan and centralize games and stories,
free of any commercial interference. Participants were relational problems of children would better be solved,
excluded from the study if they were not interested in social capabilities would improve, and potential issues
continuing to cooperate during therapy, the presence would emerge through such mediums earlier.
of other psychiatric disorders, and the absence of more
than two sessions; however, there were no missing cases. The reason leading us to design this study is that although
children with ADHD attempt to forge relationships with
Results peers, these attempts are often viewed as negative,
immature, and intrusive owing to ineffective social skills,
Forty‑four ADHD children were primarily assessed failure in social processing, and social cognition. These
regarding their eligibility for participation in the study, individuals are also likely to be unaware of their impaired
among which 30 met the study criteria and were randomly social skills, which leads to difficulties maintaining peer
allocated into two groups of the study (n = 15 for each relationships.[2] Problems with peer acceptance and
group). None of the participants in the studied groups interactions are common, and peer rejection predicts
withdrew from the study. Finally, the current study was later global impairment, cigarette smoking, delinquency,
conducted on 30 children with ADHD. The mean age and anxiety; hence, it seems important to address peer
of all participants was 8.5 (1.72), and separately females rejection to improve the long‑term outcomes that these
were 36% and males were 64%, which are shown in children will probably struggle with in the future.[3]
Table 2 based on two study groups. The two study groups Additionally, directive methods would not work for
were statistically similar in terms of age (P value = 0.20) these children;[14,21] therefore, most studies in this field
and gender distribution (P value = 0.37). are focused on interventions such as play therapy and
storytelling.
The mean (SD) of social skills and its subscales in the two
studied groups at pre‑test and post‑test are presented in Children through playing find a good opportunity
Table 3. In the intervention group, there was a significant to interact, communicate effectively, take turns, and
improvement in the mean level of studied variables at emulate behaviors that are rewarded by the coaches.
post‑test evaluation (P < 0.05). There was no significant The child gradually internalizes these new skills and
difference between pre‑ and post‑test in the control more pleasant behaviors. By playing, children express
4 Journal of Education and Health Promotion | Volume 12 | September 2023
 Karbasi Amel, et al.: Play therapy and storytelling for children with ADHD

their feelings more easily and develop new relationships,

groups)
(within

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

>0.05
which increases their happiness and adaptability to

P
Cooperation (X̅ ±SD)
the surrounding environment. This, in turn, reduces

11.47±6.94 11.33±5.76
attention deficit/passivity problems and increases

Post‑test
their internal capacities to adapt to the environment.

<0.05
Meanwhile, storytelling process actually changes the
child’s attention and would alter it from passive to active.
Pre‑test 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,
groups)
(within

>0.05
fears, and emotions.
P
Responsibility (X̅ ±SD)

However, in reviewing the background, these studies

15.73±6.19 15.33±6.20
Post‑test

just examined the positive effects of interventions on

<0.05

reducing behavioral symptoms and signs of ADHD and

indicated to be efficient methods: applying just play
therapy,[22‑25] just storytelling,[6,14,26] and the combination
Social Skill Subscales

Pre‑test

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
groups)
(within

and Teeling (2016),[29] Adlerian play therapy made a

>0.05
P

decline in disruptive behavior and poor social skill of

Self‑control (X̅ ±SD)

three participants, and the changes in desired behavior of

12.07±5.58 12.13±5.65
Post‑test

participants were consistent. Ashori et al. (2019)[30] showed

<0.05

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
Pre‑test
Table 3: Mean differences in social skill scores before and after intervention

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
groups)

significant improvement. Hosseinnezhad et al. (2020)[31]

(within

>0.05
P

showed that narrative therapy is more effective than anger

Self‑expression (X̅ ±SD)

management training in terms of increasing academic

19.13±5.84 18.40±4.48
Post‑test

self‑efficacy and social relations. Yati et al. (2017)[32] bore

<0.05

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
Pre‑test

children’s anxiety levels.

Limitation and recommendation

Along with the strengths of this study such as novelty
groups)
(within

>0.05

and placing a high value on the social skills of children

P

with ADHD rather than just alleviating their symptoms,

Social Skills (X̅ ±SD)

there are some limitations. First and foremost, we

57.2±19.26
Post‑test

utilized convenient sampling; hence, random sampling

<0.05

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.
58.4±21.53
Pre‑test

Furthermore, we failed to follow up after intervention

because of financial constraints; therefore, more regular
follow‑up programs should be considered. It is also
group (n=15)

group (n=15)

suggested that a course of treatment should be held at

Intervention

P (between
Variables

school time and parenting skills be integrated with such

groups)
Control

kinds of interventions to make the whole process more

effective.
Journal of Education and Health Promotion | Volume 12 | September 2023 5
 Karbasi Amel, et al.: Play therapy and storytelling for children with ADHD

Conclusion Conflicts of interest

There are no conflicts of interest.
In summary, ADHD symptoms hinder children’s
progress in many situations and aspects. As a prevalent References
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