School Psychology Review,

2011, Volume 40, No. 3, pp. 352–366

The Stories They Tell: Story Production Difficulties of

Children With ADHD

Benjamin D. Freer
Fairleigh Dickinson University

Angela Hayden, Elizabeth P. Lorch, and Richard Milich

University of Kentucky

Abstract. This study investigated differences in the structure of stories created by

children with attention deficit hyperactivity disorder and their comparison peers.
Children created one story without pictorial cues and one with pictorial cues
available. Without cues, children with attention deficit hyperactivity disorder told
fewer stories based on a character’s goal than did comparison children. Even
those children who constructed goal-based stories told less coherent stories than
did comparison children. With pictorial cues and when controlling for expressive
language, the two groups of children did not differ in their production of coherent,
goal-based stories. These findings indicate that children with attention deficit
hyperactivity disorder have difficulties initiating and sustaining goal plans when
they are asked to create stories. Suggestions for future academic interventions are
discussed.

It is well documented that children with search examining comprehension of stories

attention deficit hyperactivity disorder
(ADHD) have significant academic difficul-
ties, which include higher rates of school fail-
ure and grade retention than nondiagnosed
peers (Henker & Whalen, 1989). Such diffi-
culties are thought to be related to core symp-
toms of the disorder (i.e., developmentally in-
appropriate levels of inattention, hyperactiv-
ity, and impulsivity; Barkley, 2006). These
academic deficits persist or even worsen dur-
ing childhood (Bailey, Lorch, Milich, &
Charnigo, 2009), but for reasons that are not
well understood. A promising new direction of
investigation to better understand these aca-
demic deficits has been the emergence of re-
(Lorch, Berthiaume, Milich, & van den Broek,
2007). Story comprehension is a multifaceted
concept that can involve understanding story
structure, encoding and recalling events, and
attending to important information in the
story. Early narrative comprehension perfor-
mance predicts later academic success in read-
ing and other academic areas, above and be-
yond syntactic and semantic skills (Feagans &
Applebaum, 1986; Shatil & Share, 2003).
Children who struggle with story comprehen-
sion early in life have difficulties with com-
prehension later and underperform academi-
cally in relation to their peers (Kendeou et al.,
2005). The present study extends work on

Correspondence regarding this article should be addressed to Benjamin Freer, School of Psychology,
Fairleigh Dickinson University—Metropolitan, Teaneck, NJ 07666-1914; e-mail: benjamindfreer@
gmail.com
Copyright 2011 by the National Association of School Psychologists, ISSN 0279-6015

352

story comprehension among children with
ADHD by examining the structures of stories
created by these children.
Two theoretical models of story com-
prehension offer insight into the nature of ef-
fective story construction. The first, the Story
Grammar Model, defines different types of
story events and stresses the importance of a
goal plan that leads to an overall story out-
come (Mandler & Johnson, 1977; Stein &
Glenn, 1979). A central idea from the Story
Grammar Model is that a defining story ele-
ment is a goal–attempt– outcome (GAO) se-
quence, in which the protagonist is motivated
by an initiating event that establishes an over-
arching goal (G), subsequent protagonist at-
tempts to reach that goal (A), and the resolu-
tion of the goal (O). Such GAO sequences
within stories are the critical idea units that
lead to story resolution (Goldman & Varnha-
gen, 1986; Nezworski, Stein, & Trabasso,
1982; van den Broek, 1989). Without a goal
plan, stories have no central motivation for the
characters’ actions and thus are not ‘valid’
stories. Some stories may contain multiple,
interrelated GAO sequences; such stories are
more complex than those that contain a single
GAO sequence (Stein & Albro, 1997).
The second theoretical model, the
Causal Network Model, expands the Story
Grammar Model by emphasizing the impor-
tance of causal connections among story
events in the construction of a coherent, goal-
based story (Trabasso & Nickels, 1992; Tra-
basso & van den Broek, 1985; Trabasso, van
den Broek, & Suh, 1989). Causally connected
events within a goal plan contribute signifi-
cantly to a story’s global coherence, which is
the listener’s or reader’s subjective judgment
of the logical flow and comprehensibility of
the entire narration (Habermas & Silveira,
2008). Thus, although more subjective to the
listener or reader than the presence of GAO
sequences and causal connections, coherence
is an important aspect in the evaluation of a
narrative.
To construct a coherent, goal-based
story representation, children must use several
skills, including sustaining attention and mon-
itoring the maintenance of the storyline. Main-
The Stories They Tell
taining the storyline may include following
goals with attempts and outcomes (Schank &
Abelson, 1977) and connecting events caus-
ally in order to maintain coherence (Nezwor-
ski et al., 1982; Trabasso, Secco, & van den
Broek, 1984; van den Broek, Lorch, & Thur-
low, 1996). Children with ADHD have dem-
onstrated problems understanding and using
causal relations (Bailey et al., 2009; Lorch et
al., 2007). These problems may be linked to
deficits in sustained cognitive engagement
with story content, as indexed by less time
than comparison children engaged in extended
looks at a televised story (Lorch et al., 2004)
and by patterns of response times to a second-
ary probe task that do not show the systematic
links with content that are demonstrated by
comparison children (Lorch, Milich, Astrin, &
Berthiaume, 2006). In addition, children with
ADHD have difficulty using goal plans to
organize and produce effective story represen-
tations, either from memory or when narrating
a wordless picture book (Flory et al., 2006;
Leonard, Lorch, Milich, & Hagans, 2009;
Renz et al., 2003). Although these findings
suggest that children with ADHD would have
similar difficulties in creating their own story
representations, this is a facet of story com-
prehension in which there is little prior re-
search available. Examining story creation
among children with ADHD has the potential
to offer new insights into cognitive difficulties
with story representation while minimizing the
effects of memory load necessary for story
recall tasks. Adding information about cogni-
tive difficulties can provide a more complete
picture of story representation difficulties
among children with ADHD, which in turn
may allow for more specific targeting of these
difficulties in the design of educational
interventions.
To date, only one study (Zentall, 1988)
has asked children with ADHD to create sto-
ries when provided few or no cues to story
structure. Children were asked to tell two sto-
ries that they had never heard before: one story
with no cues to guide the narration, and one in
which they were given four illustrated and
labeled cards (i.e., a dragon, a storm, gold, and
a cave) in order to offer potential organizing
353
School Psychology Review, 2011, Volume 40, No. 3
ideas from which a story representation could
be built. In the absence of cues, children with
ADHD told shorter stories than did compari-
son children. However, when given the four
pictures there was no group difference in story
length. Although Zentall’s study begins to ad-
dress whether there are diagnostic group dif-
ferences when children are asked to create
stories, the study focused primarily on lan-
guage production rather than on children’s
representation of structural features. The main
focus of the current study is children’s repre-
sentation of a goal plan and the coherence of
the stories they create.
The present study incorporated the two
story-creation tasks used by Zentall (1988) to
address the overarching question of whether
children with ADHD differ from comparison
children in creating story representations. For
each task, the two groups of children were
compared in the frequency of their valid sto-
ries (i.e., at least one GAO sequence), the
complexity of their stories (i.e., number of
GAO sequences), and the rated coherence of
their stories. It was hypothesized that, relative
to comparison children, fewer children with
ADHD would tell valid stories, and that their
stories would be less complex. In addition, the
stories told by children with ADHD were hy-
pothesized to be less coherent. Finally, the two
story tasks (i.e., no-cues, four-cues) were in-
cluded to determine the degree to which cues
to story structure would affect any differences
between children with ADHD and comparison
children. Specifically, the cues to story struc-
ture might reduce differences between groups
if they help children with ADHD with their
difficulty organizing and structuring stories.
Method
Participants
The sample included 155 children rang-
ing in age from 5.5 to 11.4 years (M ⫽ 8.83,
SD ⫽ 1.76). The children were part of the
second phase of a larger longitudinal study.
The second phase took place 21 months after
entry into the longitudinal study. Fifty-four
children had been diagnosed with ADHD and
the remaining 101 children served as a typi-
354
cally developing comparison group. The chil-
dren with ADHD were diagnosed by and re-
cruited from the Hyperactive Children’s Clinic
in the School of Medicine at the University of
Kentucky. Upon receiving parental consent,
the clinic files of the child were reviewed by
one of the authors in order to determine eligi-
bility. If eligibility criteria were met, the par-
ent and child were invited to participate in the
study.
A more extensive discussion of the ini-
tial recruitment process and eligibility criteria
can be found in Flake, Lorch, and Milich
(2007). Of particular note, children with co-
morbid behavioral and/or learning disorders
were not excluded from the study because of
the high cooccurrence of these types of disor-
ders with ADHD, but children with low IQ
and severe handicapping conditions such as
psychosis and autism were excluded from the
study.
Only children whose parental interviews
supported diagnosis of ADHD—Combined
Type were retained and contributed data for
this study. Comparison children were re-
cruited through advertisements in local news-
papers and flyers distributed throughout the
community. Interested parents were initially
screened over the phone about their child’s
history of behavior, learning, or attention
problems. Comparison children did not have
to be symptom free, but it was important that
these children did not have significant symp-
toms that normally cooccur with ADHD (see
Table 1). A semistructured interview was con-
ducted with the parent to confirm the results of
the phone interview. Only children with two
or fewer symptoms of hyperactivity/impulsiv-
ity, inattention, or oppositional defiant disor-
der were included in the study as comparison
students.
Of the 155 children participating in the
study, some children were excluded from
analysis of one of the story tasks for the fol-
lowing reasons. On the no-cues task, 15 chil-
dren indicated they could not create a novel
story (4 ADHD, 11 comparison), one compar-
ison child was inadvertently prompted by a
research assistant, and one child with ADHD
created a story that was 43 standard deviations
 The Stories They Tell

Table 1
Comparison of ADHD and Comparison Groups on Relevant Demographic Variables

ADHD Comparison
(n ⫽ 54) (n ⫽ 101)

Factor M (SD) M (SD) t p

Age (years) 9.00 (1.77) 8.73 (1.76) 0.903 .368

Gender (% male) 78% 58% 2.441 .016
Ethnicity (% white) 85% 86% 0.161 .872
Interview
Inattention 6.04 (2.46) 0.13 (.42) 23.606 ⬍.001
Hyperactivity/Impulsivity 5.89 (2.09) 0.24 (.53) 25.734 ⬍.001
Oppositionality 3.43 (2.19) 0.27 (.71) 13.271 ⬍.001
Mother’s education 14.63 (2.28) 15.83 (2.23) 3.102 .002
Language Assessmenta
Oral Expression 94.55 (12.46) 107.99 (15.17) 5.544 ⬍.001
Conners Parent Rating Scalea
Oppositional 67.80 (12.05) 48.75 (7.53) 12.054 ⬍.001
Inattention 70.22 (10.06) 47.77 (5.91) 17.462 ⬍.001
Hyperactivity 77.72 (9.31) 49.78 (6.29) 22.113 ⬍.001
ADHD Index 72.80 (8.41) 47.92 (5.84) 21.523 ⬍.001

Note. ADHD ⫽ attention deficit hyper activity disorder.

a
The Conners Parent Ratings and the language assessment were obtained at Phase 2 of data collection.

above the mean in idea units. The exclusions
resulted in a sample of 49 children with
ADHD and 89 comparison children included
in analyses of the no-cues task. On the four-
cues task, two children indicated they could
not create a novel story (2 comparison) and
one child with ADHD created a story that
was 7 standard deviations above the mean in
idea units. The exclusions resulted in a sample
of 53 children with ADHD and 99 comparison
children included in the analyses of the four-
cues task. There were no diagnostic group
differences in the distribution of children ex-
cluded from analyses of either the no-cues
task, ␹2 ⫽ 0.248, p ⬎ .20, or the four-cues
task, ␹2 ⫽ 0.003, p ⬎ .20.
Measures
Interview. A semistructured interview
was conducted with the parent to confirm the
child’s diagnosis of ADHD on the first day of
the study. The interview was similar to the
Children’s Interview for Psychiatric Syn-
dromes—Parent Version (Weller, Weller,
Rooney, & Fristad, 1999), but was limited to
the Diagnostic and Statistical Manual (4th ed.,
text rev.; American Psychiatric Association,
1994) criteria for ADHD and oppositional de-
fiant disorder. The interview procedure has
been used in previous research and achieved
inter-rater reliability above 95% for the num-
ber of ADHD symptoms endorsed by the par-
ent (e.g., Lorch et al., 1999).
Conners Parent Rating Scale. As fur-
ther validation of the diagnostic categories, the
Conners Parent Rating Scale—Revised (Con-
ners, 1997), was administered during the cur-
rent phase. Children with ADHD scored sig-
nificantly higher than comparison children on
all scales, providing evidence of the stability
of the diagnostic categories (see Table 1).
Story measures. Children were asked
to create two different stories that they had
never heard before. First, children were in-
structed to make up a story in the absence of
355
School Psychology Review, 2011, Volume 40, No. 3
cues to content or organization (no-cues task).
Second, children were instructed to make up a
story based on four pictures/words (four-cues
task), each of which was presented on a dif-
ferent card. The cards depicted a cave, a
storm, gold, and a dragon (Zentall, 1988).
Children were told to create a story that in-
cluded each of the four words. They were
given as much time as needed to complete
each story.
The first hypothesis addressed in the
current study was that children with ADHD
would produce valid, goal-based stories less
frequently than comparison children. Guided
by story grammar theory (Stein & Albro,
1997), a narrative was coded as a valid story if
it included at least one GAO sequence. The
second hypothesis was that comparison chil-
dren would create more complex stories than
children with ADHD. Complexity was opera-
tionalized as the total number of GAO se-
quences in each narrative. For both of these
measures, a GAO sequence was determined
present based on the inclusion of the following
story grammar categories: an initiating event
setting up a goal (G), an attempt (A), and an
outcome of the attempt (O).
The story grammar categories that were
components of GAO sequences were defined
as follows. The initiating event set up the
overall goal of the characters within the story.
An initiating event was coded if the child
stated a situation that needed to be resolved. A
narrative with an initiating event will inher-
ently contain a story goal (though it may be
implicit). An attempt was an action that was
either explicitly or implicitly connected to the
goal. An outcome was a result of the protag-
onist’s action, in relation to the goal. A story
could include several outcomes.
The final hypothesis was that children
with ADHD would tell less coherent stories
than comparison children. Coherence was de-
fined as the degree to which the entire narra-
tion maintained a storyline and logical flow
(Habermas & Silviera, 2008; Lorch, Milich,
Flake, Ohlendorf, & Little, 2010). Thus, each
story was rated in terms of global coherence
on a scale of 1– 4 (1 ⫽ Not at all coherent, 4 ⫽
Very coherent). The criteria for the four levels
356
were as follows: a score of 1 reflected poor
transitions from one idea to the next, poor
connections while talking about the same idea,
poor overall flow (choppy), significant diffi-
culty explaining the sequence of events, and
little or no story line maintained; a score of 2
signified some appropriate transitions to new
ideas and connections within an idea, but dif-
ficulty explaining the sequence of events, with
only a few parts of the storyline maintained; a
score of 3 reflected appropriate transitions to
new ideas and connections within an idea with
good overall flow, only minor problems with
transitions or connections, explanation of the
sequence of events but with some ambiguities;
and a score of 4 signified appropriate transi-
tions to new ideas and connections within an
idea with good overall flow, and clear expla-
nation of the sequence of events with no or
few ambiguities. See Appendix for examples
of valid and invalid stories that vary in
coherence.
Oral and Written Language Scale
(OWLS). The OWLS is an individually ad-
ministered test that measures receptive and
expressive language for children and adults
from 3 to 20 years. The expressive language
portion of the OWLS was used in the current
study. In this portion of the test, the child is
asked to answer questions, complete sen-
tences, generate a sentence or sentences cor-
responding to visual stimuli, and correct gram-
mar. The internal consistency and test–retest
reliability for this measure are .87 and .81,
respectively. Children with ADHD are more
likely to experience problems with expressive
language than nonreferred peers (Kim & Kai-
ser, 2000; Leonard, Milich, & Lorch, 2011;
Purvis & Tannock, 1997). Prevalence esti-
mates for the comorbidity of ADHD and ex-
pressive language disorders ranges from 10%
to 33% (Cantwell & Baker, 1987; Riccio,
Hynd, Cohen, Hall, & Molt, 1994). The inclu-
sion of the OWLS scores as a covariate in the
analyses below allows for determination of
effects of diagnostic status above and beyond
expressive language ability.

Procedure
Children were seated across from a
trained undergraduate experimenter who was
blind to the purpose of the study and to the
child’s diagnostic group. Both storytelling
tasks were recorded on audiotape and video-
tape. The stories were transcribed verbatim
from the recordings by a different undergrad-
uate student blind to group status and study
hypotheses and were checked for accuracy by
a second transcriber. Final transcriptions ex-
cluded questions to the experimenter, refer-
ences to the test, and self-regulatory language
(e.g., “umm,” “uh”). Transcriptions were
parsed into idea units, where an idea unit was
equivalent to a single idea or event.
The first author, who served as the pri-
mary coder, parsed the transcriptions and es-
tablished criteria for coding based on previous
literature on story grammar categories and
subjective coherence ratings (Mandler &
Johnson, 1977; Stein & Albro, 1997; Stein &
Glenn, 1979). This primary coder scored all
stories for each story representation measure
discussed below, and trained secondary coders
in the criteria for scoring. The primary coder
did not serve as an experimenter or transcriber
and was blind to the diagnostic status of the
child when scoring each story. The no-cues
task preceded the four-cues task for every
child. Although typically task order would be
counterbalanced, this was not done in the pres-
ent study because carryover effects seemed
much more likely if children first told stories
cued by pictures rather than if they first told
stories without cues. If children first had told
stories with pictures, they might have incor-
porated the structure or content of the first
story when asked to tell a second story without
cues. Given that tasks had to be presented in
this order, results from the two tasks were not
compared.
To investigate basic deficits of children
with ADHD, children were tested off stimu-
lant medication. Only children not on medica-
tion or who could discontinue medication
for 24 hr were included in the study. This
procedure is consistent with most laboratory
studies of children with ADHD (e.g., Bailey et
The Stories They Tell
al., 2009; Berman, Douglas, & Barr, 1999;
Rucklidge & Tannock, 2002; Van De Voorde,
Roeyers, Verté, & Wiersema, 2010). In addi-
tion, recent research has suggested that thera-
peutic medications, although successful at ad-
dressing problems concerning attention and
concentration, may not influence higher order
cognitive deficits that these children exhibit
(Derefinko, Bailey, Milich, Lorch, & Riley,
2009). Parents were contacted the day before
testing to remind them to discontinue medica-
tion and upon arrival for testing were asked
whether the child was medication free. If the
child had taken medicine the day of the test-
ing, they were asked to reschedule their ses-
sion for a later date.
Parental consent for the study was ob-
tained prior to each child’s participation. Chil-
dren completed the tasks for this study as part
of one session that lasted approximately 11⁄2
hr. The children were offered frequent breaks,
the mixture of tasks provided variety, and chil-
dren were allowed to choose a small toy at the
beginning and end of the testing session to
maintain their interest and motivation. The
participating families were paid $15 for the
session.
Inter-rater Reliability
In order to estimate inter-rater reliabil-
ity, two secondary coders who were blind to
the diagnostic status of the child scored all
stories for coherence and a subset of 50 stories
for the inclusion of a GAO sequence and the
total number of GAO sequences. The inter-
rater reliability for the inclusion of at least one
GAO sequence was ⌲ ⫽ .96 and for the total
number of GAO sequences was r ⫽ .93, and it
was r ⫽ .88 for the story grammar categories
of the GAO. The inter-rater reliability for
story coherence was r ⫽ .86.
Analyses
The primary focus of the data analyses
addressed whether children with ADHD differ
from comparison children in creating story
representations that include essential structural
features as defined by theoretical models of
story representation. A secondary focus was to
357
School Psychology Review, 2011, Volume 40, No. 3
investigate whether the presence of cues af-
fected story production differentially for chil-
dren with ADHD compared to their nondiag-
nosed peers. The first analyses consisted of
separate multivariate analyses of variance
(MANOVA) for the no-cues and four-cues
tasks. Each MANOVA included the three de-
pendent variables of validity, complexity, and
coherence. Follow-up analyses of variance
(ANOVAs) examined each of the hypotheses
discussed above. Finally, the effects of several
covariates on storytelling ability were exam-
ined with separate multivariate analyses of
covariance (MANCOVA) in order to control
for factors other than diagnosis that could dif-
ferentially affect storytelling for the two
groups of children. The covariates included
age, gender, mother’s education, and expres-
sive language ability (measured by the OWLS
Oral Expressive Language Scale).
Each covariate was investigated sepa-
rately for both the no-cues task and the four-
cues task. Gender and mother’s education
were nonsignificant covariates. Expressive
language was a significant covariate for both
tasks (four-cues task: F[3,146] ⫽ 9.26, p ⬍
.001; no- cues task: F[3,132] ⫽ 3.54, p ⬍ .05),
as was age (four-cues task: F[3,146] ⫽ 15.27,
p ⬍ .001, no-cues task: F[3,132] ⫽ 12.60, p ⬍
.001). However, only expressive language
contributed to group differences when entered
into the pattern of analyses and thus will be the
only covariate discussed in the analyses.
Results
No-Cues Task
Prior to examining differences in story
structure for the no-cues task, the total number
of idea units produced by participants for valid
and invalid stories was compared in a Diag-
nostic Group (ADHD, comparison) ⫻ Valid-
ity (valid story, invalid story) ANOVA. Valid
stories were longer than invalid stories,
F(1,136) ⫽ 74.99, p ⬍ .001, d ⫽ 1.55, but
there was no effect of diagnostic group
F(1,136) ⫽ 1.56, p ⬎ .20, and no interaction
between diagnostic group and validity of
story, F(1,136) ⫽ 0.000, p ⬎ .20.
358
The group difference for the three de-
pendent variables in the overall MANOVA
was significant, Wilks’s ␭ ⫽ 0.864,
F(3,134) ⫽ 7.02, p ⬍ .001. As predicted in
the first hypothesis, significantly fewer chil-
dren with ADHD created a valid, goal-based
story than did comparison children,
F(1,136) ⫽ 12.48, p ⬍ .005, d ⫽ 0.61. Spe-
cifically, only 33% of children with ADHD
included at least one GAO sequence in their
stories, whereas 63% of comparison children
did so. Table 2 presents means and standard
deviations for both the no-cues and four-cues
tasks.
The second hypothesis was that diag-
nostic groups would differ in the complexity
of their stories, as measured by the total num-
ber of GAO sequences. By definition, invalid
stories contain no GAO sequences, so on av-
erage children with ADHD appeared to tell
less complex stories when both valid and in-
valid stories were considered, F(1,136) ⫽ 6.98
p ⬍ .01, d ⫽ 0.45, consistent with this hy-
pothesis. However, there was no significant
group difference when the analysis was lim-
ited to valid stories, F(1,70) ⫽ 0.03, p ⫽ .857.
The third hypothesis was that diagnostic
groups would differ on ratings of global co-
herence of the stories. When examining all
stories, those produced by children with
ADHD were rated as less coherent than
those produced by comparison children,
F(1,136) ⫽ 19.37, p ⬍ .001, d ⫽ 0.75. Of
greater significance, even when children with
ADHD told valid stories, these stories were
judged to be less coherent than the valid sto-
ries produced by comparison children,
F(1,70) ⫽ 5.01, p ⬍ .05, d ⫽ 0.54. As illus-
trated by Story 2 in the Appendix, these less
coherent yet valid stories tended to include
poorly maintained storylines and to be more
list-like, with fewer instances of transition
statements such as “and,” “then,” and
“because.”
The analyses reported above were re-
peated including oral expressive language as a
covariate. The only outcome that differed
from the original analysis was that for all
stories, the group difference in production of
GAO sequences (i.e., complexity) was no lon-
 The Stories They Tell

Table 2
Means and Standard Deviations of Story Construction Variables on the Four-Cues Task
and No-Cues Task for Children With ADHD and Comparison Children

ADHD Comparison

M (SD) M (SD) t d

No-cues task
Inclusion of GAO sequence (%) 33.00 (0.47) 63.00 (0.49) 3.53*a 0.61
Complexity (no. of GAO sequence)
All stories 0.59 (1.19) 1.18 (1.28) 2.64* 0.45
Valid stories 1.81 (1.47) 1.88 (1.15) .18 0.04
Global coherence (1–4 rating scale)
All stories 1.94 (1.01) 2.71 (0.97) 4.40*a 0.75
Valid stories 2.63 (0.89) 3.14 (0.80) 2.24* 0.54
Four-cues task
Inclusion of GAO sequence (%) 43.00 (0.50) 64.00 (0.48) 2.43* 0.40
Complexity (no. of GAO sequences)
All stories 0.74 (0.98) 1.26 (1.27) 2.63* 0.43
Valid stories 1.70 (0.77) 1.98 (1.04) 1.21 0.26
Global Coherence (1–4 rating scale)
All stories 2.11 (0.95) 2.59 (1.03) 2.77* 0.45
Valid stories 2.78 (0.74) 3.08 (0.75) 1.64 0.36

Note. ADHD ⫽ attention deficit hyperactivity disorder; GAO ⫽ goal–attempt– outcome.

*p ⬍ .05.
a
p ⬍ .05 when expressive language is covaried.

ger significant when expressive language was
covaried, F(1,134) ⫽ 2.59, p ⬎ .10.
In summary, when children told stories
without cues, children with ADHD told fewer
valid, goal-based stories and even their valid
stories were judged to be less coherent than
those told by comparison children. This was
true whether or not oral expressive language
was included as a covariate. However, the
valid stories told by children with ADHD did
not differ from those told by comparison chil-
dren in their complexity, as defined by the
number of GAO sequences.
Four-Cues Task
As in the no-cues task, a Diagnostic
Group (ADHD, comparison) ⫻ Validity (valid
story, invalid story) ANOVA investigated po-
tential differences in story length. Valid sto-
ries were longer than invalid stories,
F(1,150) ⫽ 42.69, p ⬍ .001, d ⫽ .54, and
comparison children told longer stories than
children with ADHD, F(1,150) ⫽ 6.48, p ⬍
.05, d ⫽ 0.31. There was, however, no inter-
action, F(1,150) ⫽ 0.79, p ⬎ 0.30, indicating
that the disparity in length between valid and
invalid stories was not based on diagnostic
group differences.
When cues were available, the group
difference for the three dependent variables in
the overall MANOVA was significant,
Wilks’s ␭ ⫽ 0.942, F(3,148) ⫽ 3.02, p ⬍ .05.
Consistent with the first hypothesis and the
no-cues task, fewer children with ADHD cre-
ated a valid, goal-based story than did com-
parison children, F(1,150) ⫽ 5.90, p ⬍ .05,
d ⫽ 0.40. For the four-cues task, 43% of
children with ADHD created a story with at
least one GAO sequence, whereas 64% of
comparison children did so.
The second hypothesis was that the
groups would differ in the complexity of their
359
School Psychology Review, 2011, Volume 40, No. 3
stories, as measured by the total number of
GAO sequences. Similar to the no-cues task,
children with ADHD told less complex stories
when both valid and invalid stories were con-
sidered, F(1,150) ⫽ 6.93, p ⬍ .01, d ⫽ 0.43.
However, this group difference was no longer
significant when the analysis was limited to
valid stories, F(1,84) ⫽ 1.48, p ⬎ .20.
The third hypothesis was that the diag-
nostic groups would differ in ratings of global
coherence of the stories produced in the four-
cues task. Consistent with this hypothesis and
the no-cues task, the stories produced by chil-
dren with ADHD were rated as less coherent
than those of comparison children,
F(1,150) ⫽ 7.64, p ⬍ .01, d ⫽ 0.45. However,
when only valid stories were analyzed, group
differences were no longer significant,
F(1,84) ⫽ 1.48, p ⬎ .10.
Significant group differences in validity,
complexity, and coherence when all stories
were analyzed were no longer significant
when variations in expressive language were
covaried: validity, F(1,148) ⫽ 0.33, p ⬎ .10;
complexity, F(1,148) ⫽ 1.13, p ⬎ .10; coher-
ence, F(1,148) ⫽ 0.85, p ⬎ .10.
In summary, when children told stories
guided by cues, children with ADHD told
fewer valid, goal-based stories than did com-
parison children, and the stories told by chil-
dren with ADHD were less complex and co-
herent than those told by comparison children.
However, group differences in complexity and
coherence were no longer significant when
valid stories only were considered. In addition,
when expressive language was used as a co-
variate, group differences on all three depen-
dent variables were no longer significant. This
suggests that variation in oral expressive lan-
guage ability may account for much of the
deficit that children with ADHD exhibited in
the four-cues task. This is in contrast to the
minimal effect of expressive language ability
on group differences in the no-cues task.
Discussion
The present study employed a story cre-
ation procedure (Zentall, 1988) to investigate
the structure of stories produced by children
360
with ADHD and their comparison peers. How-
ever, instead of Zentall’s focus on diagnostic
differences in language production, the current
study examined children’s ability both to in-
corporate a goal plan into the stories and to
create coherent stories. In the current study,
when all stories were considered, children
with ADHD told fewer valid stories and their
stories were less complex and less coherent
than those told by comparison children. Fol-
low-up tests covarying expressive language or
including only valid stories revealed that al-
though group differences in complexity and
coherence became nonsignificant in the four-
cues task, group differences in story coherence
persisted in the no-cues task.
The no-cues task required children to
generate stories with no guidance. In this task,
most children with ADHD did not even initi-
ate a goal plan, instead describing events lack-
ing organization or focus. The finding that
children with ADHD included a goal plan
significantly less often than comparison chil-
dren is consistent with previous research indi-
cating that children with ADHD have diffi-
culty initiating and sustaining a goal plan
when narrating or retelling stories (Flory et al.,
2006; Leonard et al., 2009; Renz et al., 2003).
There are a number of possible explana-
tions for why children with ADHD are less
likely to tell valid stories. One candidate,
based on prior studies, is that children with
ADHD have a poor understanding of the nec-
essary components and typical structure of a
story (Flory et al., 2006; Lorch et al., 2006).
However, such an interpretation is inconsis-
tent with the results from the four-cues task in
that the two groups did not differ in the cre-
ation of valid stories when expressive lan-
guage was covaried. This finding suggests that
conditions exist in which children with ADHD
are able to incorporate goal plans in their
stories.
A second interpretation for the low rate
of valid stories among children with ADHD is
that these children may have difficulty creat-
ing or sustaining the organization of story
events around a goal. Such an interpretation
would be consistent with research document-
ing the difficulties these children have with

executive functioning, including planning,
working memory, and sustaining attention.
Thus, children with ADHD may have diffi-
culty in planning how a character’s goal may
lead to other actions, in keeping a goal active
in working memory in order to organize
events, and in sustaining attention to se-
quences of events. This interpretation is in
agreement with the findings of previous stud-
ies using different methodologies. For exam-
ple, young children with ADHD included
fewer goal-based events than comparison chil-
dren when asked to retell stories that had been
told by their mothers or when narrating a story
from a wordless picture book (Flory et al.,
2006; Leonard et al., 2009; Renz et al., 2003).
Across all of these studies, including the pres-
ent one, children with ADHD showed diffi-
culty in identifying a goal and maintaining it
to guide and organize the overall story
structure.
The second major finding of the no-cues
task was that children with ADHD told less
coherent stories than did comparison children,
even when analyzing data from valid stories
only or including expressive language as a
covariate. This was true despite the lack of
group difference in story complexity or story
length under the same conditions. This pattern
of results may reflect the fact that the achieve-
ment of a goal-based story that contains one or
more GAO sequences is necessary but in no
way sufficient to ensure a truly effective story.
Whereas a valid story merely requires the in-
clusion of one or more GAO sequences, the
global coherence ratings depend on the child
making clear transitions from one idea to the
next, stating complete thoughts that maintain a
storyline, and creating a sequence of events
that is both temporally accurate and logically
consistent.
The difficulty children with ADHD have
in constructing coherent narratives, especially
without cues to aid them, is not unique to story
creation tasks but also has been found when
children recalled television programs (Lorch,
Milich, Flake, Ohlendorf, & Little, 2010).
Given the consistency of this deficit across
diverse task requirements (story creation,
story production from picture books, and free
The Stories They Tell
recall of a televised show), it may be benefi-
cial to consider examination of characteristics
associated with ADHD that may contribute to
problems in creating coherent narratives.
Children with ADHD have been found
to be deficient in a number of metacognitive
skills (Barkley, 1997; Flory et al., 2006; Lorch
et al., 2007) required for the production of
coherent narratives. These skills include care-
ful reflection and planning of key story events;
perspective taking so as to recognize and com-
municate information necessary for the lis-
tener to understand the story; sustaining atten-
tion to the goal plan; working memory to set
the stage for new events; and making causal
connections between previous and future
events. Any or all of these deficiencies may
contribute to reduced coherence of narratives
among children with ADHD.
Groups exhibited differences in the
four-cues task only when taking all stories into
consideration and without covariates. When
accounting for expressive language and/or ex-
amining only valid stories, any group differ-
ences were no longer significant. This pattern
suggests that providing cues to children with
ADHD may aid these children in their story
construction in several ways. First, the cues
may allow these children to constrain the topic
of their story to the pictures presented to them.
Second, constraining the story topic and di-
recting children to use each cue in their story
may increase the likelihood that they will con-
nect the pictures with one another and include
a goal plan. Finally, the presence of cues
throughout storytelling may serve as visual
reminders of the story that the child is creat-
ing, lessening the cognitive load placed on
these children. Thus, the cues may have aided
in planning and remembering the central com-
ponents of the story.
The current results can offer unique and
important insights into the nature of story rep-
resentation for children with ADHD in the
academic and perhaps even in the social
realm. Regarding academics, early story rep-
resentation predicts later achievement (Fea-
gans & Applebaum, 1986; Kendeou et al.,
2005; Shatil & Share, 2003). As such, the
current study provides insight into how limi-
361
School Psychology Review, 2011, Volume 40, No. 3
tations in story construction may affect later
achievement for these children—namely, chil-
dren with ADHD may receive lower grades
than comparison peers on the numerous stories
that they are asked to compose throughout
their education because of deficits in establish-
ing a goal plan and maintaining coherence,
particularly when not given explicit prompts.
In addition to academic problems, chil-
dren with ADHD also experience social diffi-
culties (Barkley, 2006). Symptoms associated
with ADHD (e.g., the tendency to interrupt
conversations, impatience with turn-taking)
can lead to social rejection from peers (Milich
& Landau, 1982). Everyday social interaction
also involves recounting stories of past events
to one’s peers. Children with ADHD may be
more likely to recount events that have no
clear goals and little coherence (Leonard et al.,
2009, Milch-Reich, Campbell, Pelham, Con-
nelly, & Geva, 1999). If similar problems oc-
cur during social interaction, listeners may be
confused and unable to respond meaningfully,
which could have ramifications for social out-
comes. The findings of the current study sug-
gest avenues for remediation. At the most ba-
sic level, the results of this study and others
(Flory et al., 2006; Leonard et al., 2009; Renz
et al., 2003) indicate that educators cannot
assume that children with ADHD understand
the importance of characters’ goals in struc-
turing a story, either when children tell a story
or when they comprehend a story presented to
them. This suggests that educators should
place more emphasis on teaching children
what a goal is and how it functions in moti-
vating story events. Further, children can be
taught the importance of integrating goals, at-
tempts, and outcomes into a coherent story
representation (Berthiaume, 2006). Teaching
children with ADHD this information using a
story mapping technique (Boulineau, Fore,
Hagan-Burke, & Burke, 2004; Gardill & Ji-
tendra, 1999) and/or a self-questioning tech-
nique (Manset-Williamson, Dunn, Hinshaw,
& Nelson, 2008; Taylor, Alber, & Walker,
2002) may be extremely useful. These tech-
niques may be particularly suitable for chil-
dren with ADHD because both help children
to organize information in an explicit fashion.
362
Several limitations of the current study
should be considered. The first class of limi-
tations concerns characteristics of the story-
telling tasks and procedures. As discussed
above, all children first completed the no-cues
task followed by the four-cues task, confound-
ing task and order. Because of the possibility
of order and practice effects, a comparison of
conditions was not conducted. However, in
our judgment, it would have been a more
serious problem to allow the no-cues task to be
contaminated by the experience of creating a
story directed by cues. In addition, the most
important findings of the study emerge from
the no-cues task, which was not influenced by
a prior storytelling task. Although it is possi-
ble that the no-cues task served as practice that
could improve performance on the four-cues
task, for no child did the content of the four-
cues task story resemble the content of the
no-cues task story.
Another limitation related to the tasks is
that the four cues used in the current study
may have directed children towards an arche-
typal storyline (e.g., a dragon guarding gold in
a cave with a storm outside occurred in 78% of
all goal-based stories). As such, the current
four-cues task may lack sensitivity to detect
potential group differences. It would be useful
to determine whether children with ADHD
can benefit from less directive cues to story
structure.
A second class of limitations concerns
characteristics of the sample. One issue is that
a number of analyses were restricted to chil-
dren telling valid stories. Although this restric-
tion did not affect detection of group differ-
ences for the no-cues task, it may have influ-
enced that of the four-cues task. As a result,
interpretation of failures to find group differ-
ences in the four-cues task must be made with
particular caution. Research with a larger sam-
ple of children with ADHD can produce a
better understanding of the specific similarities
and differences in story production between
diagnostic groups.
A second sampling issue concerns the
exclusion and inclusion criteria for the ADHD
group. First, children diagnosed with the inat-
tentive subtype of ADHD were excluded be-

cause research suggests that the inattentive
subtype of ADHD may be a separate disorder
from the combined type (Milich, Balentine, &
Lynum, 2001). In future studies, researchers
may consider including children with the in-
attentive subtype of ADHD. Second, children
with comorbid learning disorders were not
excluded from the ADHD group. As Barkley
(1997) argues, the high cooccurrence of atten-
tion and achievement problems among chil-
dren with ADHD or learning disabilities
makes differential diagnosis problematic. In
addition, our measures did not allow for the
determination of the number of participants
with comorbid learning disabilities. However,
the current study reduced the effect of this
problem because children were not required to
decode text and analyses controlled for ex-
pressive language. Third, we relied upon pa-
rental report to confirm that their child was
free from medication in the 24 hr leading up to
the study, but did not have an independent
means of verifying the child’s medication
status.
In summary, the present study provides
evidence that children with ADHD have def-
icits in the creation of goal-based stories in
contrast to their comparison peers. Specifi-
cally, children with ADHD told fewer stories
with a goal structure and created less coherent
story representations. If cues were present and
expressive language was included as a cova-
riate, these diagnostic group differences were
not observed, suggesting that children with
ADHD may derive some benefit from cues
that imply a story structure. The findings add
to the growing understanding of differences in
higher order cognitive processing of children
with ADHD and comparison children. Be-
cause early narrative skills affect later aca-
demic performance (e.g., Kendeou et al.,
2005), the results have implications for the
design of academic interventions for children
with ADHD that focus on directing children’s
attention to the importance of characters’
goals and how to use goals to motivate and
structure a coherent story representation.
Appendix
Examples of Stories Created by
Participants
The Stories They Tell
1. Valid Story, Rated Coherence ⴝ 4
(High)
Once there was a ghost that used to eat
kids every once in a while every about a week
or so. Then one day he came to a kid’s house
and there was another ghost trying to eat the
kid. Then when he saw the ghost he was like,
“hey I’m gonna eat this kid not you.” Then the
other ghost was like, “no it’s my kid.” “No it’s
mine.” “No it’s mine.” And they kept on ar-
guing until they just decided to split the kid in
half. One ghost got the chest down; one ghost
got the chest up. And then they always went
child hunting together and they always split
the halves and each time they switched.
2. Valid Story, Rated Coherence ⴝ 2
(Low)
There was dinosaur named Tom. He
went out and to get something to eat for his
children and he saw a friend of his and he went
home with him and left his children. Then it
started to rain and then he remembered about
his children and he went home as fast as he
could and they were fine, playing in the pud-
dles. And he would never do that again be-
cause that’s scared them. And then he would
invite friends over sometimes but he wouldn’t
go to friends without his children again.
3. Invalid Story, Rated Coherence ⴝ 1
(Low)
Once upon a time there was two little
chickens, and one said “bawk, bawk” and the
other said “moo, moo”. And then, a little
chicken, the two little chickens had just par-
tied at a chicken museum. And then they went,
all the chickens said “bawk, bawk” and the
other chicken said “moo, moo”, so he said
“moo, moo” and the other said, “huh?” I never
said if all the chickens slide down
the…chickens that went “moo, moo”, and you
know why they do that? Cause he’s a chicken
that goes “wee wee wee” all the way home.
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Action Editor: Joseph Betts 䡲
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School Psychology Review, 2011, Volume 40, No. 3

Benjamin Freer, PhD, is Assistant Professor in the School of Psychology at Fairleigh

Dickinson University—Metropolitan. His research addresses the development of atten-
tion, inhibition, working memory, and comprehension processes, especially among chil-
dren diagnosed with ADHD. He also conducts research on the effect of maltreatment on
development and the effectiveness of teaching the logic of the scientific method to
elementary students.

Angela Hayden, PhD, is a postdoctoral fellow at the University of Kentucky. Her research
addresses story comprehension deficits exhibited by children with ADHD, with a partic-
ular focus on intervention. Her interests also include infant perception of emotion and
ethnicity.

Elizabeth Lorch, PhD, is Professor of Psychology and Associate Dean for Research and
Graduate Studies in the College of Arts and Sciences at the University of Kentucky. Her
primary research interests concern the development of attention and comprehension
processes, both in typically developing children and children diagnosed with ADHD. She
also studies instructional methods to improve children’s understanding of the scientific
method.

Richard Milich, PhD, is Professor and Provost’s Distinguished Service Professor in the
Department of Psychology at the University of Kentucky. He has been an active re-
searcher in the area of ADHD for over 30 years. His research has addressed a variety of
topics germane to the problems experienced by children with ADHD, including the peer
problems of children with ADHD; the effects of stimulant medication and behavioral
interventions in the treatment of ADHD; the cognitive difficulties of these children, with
a special emphasis on story comprehension problems; and classification issues associated
with this disorder.

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