Journal of Abnormal Psychology
2000, Vol. 109, No. 2, 321-330
Copyright 2000 by the American Psychological Association, Inc.
0021-843X/00/$5.00 DOI: 10.1037/10021-843X.109.2.321
Comprehension of Televised Stories in Boys With Attention
Deficit/Hyperactivity Disorder and Nonreferred Boys
Elizabeth Pugzles Lorch, Richard Milich, and
Rebecca Polley Sanchez
University of Kentucky
Paul van den Broek
University of Minnesota
Stacey Baer, Kim Hooks, Cynthia Hartung, and Richard Welsh
University of Kentucky
Two studies compared comprehension of televised stories by 7- to 12-year-01d boys with attention
deficit/hyperactivity disorder (ADHD) and nonreferred comparison boys. Boys watched one show with
toys present and one with toys absent. Visual attention was continuously recorded, and recall was tested
after each show. Across studies, visual attention was high with toys absent but decreased sharply with
toys present for boys with ADHD. Groups showed similar levels of cued recall of discrete units of
information regardless of differences in attention. When recall tasks and television story structure
required knowledge of relations among events, the reduced attention of boys with ADHD interfered with
recall. Although visual attention of comparison boys also decreased to some extent with toys present,
there was no such decrement in recall. Implications of the difficulties children with ADHD have in
integrated story comprehension are discussed.
Attention deficit/hyperactivity disorder (ADHD) is one of the
most common childhood behavior problems; prevalence estimates
are as high as 10% of the school-age population (Barkley, 1990).
These children are likely to experience reading problems and
other academic difficulties (O'Neill & Douglas, 1991; Semrud-
Clikeman et al., 1992). Thus, knowledge of the cognitive process-
ing capabilities of children with ADHD is critical to understanding
and stimulating the academic performance of these children.
Much research on the cognitive processing of children with
ADHD has focused on elucidating the specific nature of the
attention deficit experienced by these children (e.g., Douglas,
1983; Halperin et al., 1990; Whalen, 1989). Given that attentional
problems are core symptoms of ADHD, this emphasis is logical.
However, the focus on isolating the specific attention deficits of
children with ADHD has led to attempts to obtain "pure" measures
of sustained or selective attention. As such, laboratory procedures
Elizabeth Pugzles Lorch, Richard Milich, Rebecca Polley Sanchez,
Stacey Baer, Kim Hooks, and Cynthia Hartung, Department of Psychol-
ogy, University of Kentucky; Paul van den Broek, Psychological Founda-
tions of Education, University of Minnesota; Richard Welsh, Department
of Psychiatry, University of Kentucky.
This research was supported by a National Institutes of Health Biomed-
ical Research Support grant; the Department of Psychiatry, University of
Kentucky; and National Institute of Mental Health Grant 5 R01 MH47386-
02. We appreciate the assistance of Tammy Campbell, Elliot Inman, Kari
Krane, Philip Auter, and a number of very able undergraduate assistants.
Correspondence concerning this article should be addressed to Elizabeth
Pugzles Lorch, Department of Psychology, University of Kentucky,
Lexington, Kentucky 40506-0044. Electronic mail may be sent to
using relatively simple stimuli have been emphasized, such as
vigilance procedures in which children monitor for the occurrence
of a target event.
Although these traditional laboratory procedures have produced
valuable information, they have important limitations. As Whalen
(1989) noted, tasks are often artificial and monotonous, providing
the children with little motivation for performance. In addition,
questions have been raised as to whether results from these tasks
predict performance in settings outside the laboratory (Pelham &
Milich, 1992). Finally, tasks directed at the isolation of specific
deficits provide little information about the nature of more com-
plex cognitive processing by children with ADHD (Milich &
Lorch, 1994). Except for research investigating executive func-
tioning in children with ADHD (Barkley, 1997; Pennington,
Groisser, & Welsh, 1993), very few studies have examined higher
order components of cognitive processing in addition to attention.
In particular, very little is known about specific ways in which
children with ADHD may differ from nonreferred children in their
cognitive processing of complex, coherent information such as that
represented in stories.
The present studies are designed to address these limitations by
examining the story comprehension of boys with ADHD and
nonreferred comparison boys and the relation of story compre-
hension to patterns of attention. These studies extend a series of
investigations (Landau, Lorch, & Milich, 1992; Lorch, Milich,
et al., 1987; Milich & Lorch, 1994) that complement traditional
laboratory work on attentional difficulties in children with ADHD
by examining children's attention and cognitive processing within
the context of television viewing. This approach has several ad-
vantages. Given that the average school-age child watches 20 hr or
more of television per week (Anderson, Lorch, Field, Collins, &
Nathan, 1986), it permits procedures that reflect children's every-
322 LORCH ET AL.
day experiences. In addition, children have been shown to be
active, strategic viewers of television from an early age (Anderson,
Lorch, Field, & Sanders, 1981; Huston & Wright, 1983; Lorch,
Anderson, & Levin, 1979), demonstrating that television program-
ming can actively engage children's attention. Television studies
also allow for systematic examination of the relation between
visual attention and comprehension (Field & Anderson, 1985;
Lorch et al., 1979; Pezdek & Hartman, 1983) as well as factors that
mediate this relation (Alwitt, Anderson, Lorch, & Levin, 1980;
Calvert, Huston, Watldns, & Wright, 1982). Finally, structural
properties defined in research on recall of written stories also
predict children's recall of televised stories (van den Broek, Lorch,
& Thurlow, 1996). Therefore, the study of children's attention to
and comprehension of television provides a rich context for gain-
ing information about children' s higher order cognitive processing.
The utility of the approach is illustrated by earlier findings.
Lorch, Milich, et al. (1987) presented brief segments of the edu-
cational program "3-2-1 Contact" to boys with ADHD and to
comparison boys. This program was designed to communicate
scientific information and stimulate children's interest in the sci-
entific method. Appealing toys were available as an alternative
activity to viewing the program. Visual attention was continuously
recorded throughout the program, and cued recall of content was
tested. The results suggested that boys with ADHD could divide
their attention strategically between television viewing and toy
play: These children attended half as much as the comparison boys
(26% vs. 52%) but remembered a similar amount of information
from the program.
Landau et al. (1992) replicated the procedures of Lorch, Milich,
et al. (1987), but each child viewed two brief segments of "3-2-1
Contact," once with toys present and once with toys absent.
Consistent with the earlier findings (Lorch, Milich, et al., 1987),
boys with ADHD attended far less than comparison boys when
toys were present (34% vs. 60%). When toys were absent, how-
ever, the groups did not differ in visual attention (ADHD, 92%;
comparison, 96%). These results suggest that boys with ADHD are
capable of sustaining attention when viewing a brief educational
program but are less likely to do so when an appealing alternative
is available. As in the Lorch, Milich, et al. (1987) study, there were
no significant differences between the groups in cued-recall per-
formance, even when toys were present. One interpretation of the
pattern of results across the two studies is that children with
ADHD distribute their attention more broadly than nonreferred
children but not always less effectively (see Ceci & Tishman,
1984). The cued-recall testing in these studies emphasized discrete
units of information, with much of the information presented both
anditorily and visually. In such a situation, a broad distribution of
attention may be consistent with task demands, resulting in similar
performance by the two groups of children.
The present studies extended the methodology of the earlier
investigations to examine several issues pertaining to story com-
prehension of children with ADHD. The basic designs replicated
Landau et al. (1992) in that boys with ADHD and comparison boys
watched two shows, one with toys present in the room and one
with toys absent. However, the shows represented a more typical
program length (i.e., 23 min with commercials excluded) than
those used in the Landau et al. study (11-14 min). Visual attention
was continuously recorded, and recall of content was tested after
each show. Several changes from the Landau et al. (1992) study
permitted the examination of additional issues.
Whereas Landau et al. (1992) focused primarily on memory for
discrete, factual information from the "3-2-1 Contact" segments,
the current studies provide an important extension of this knowl-
edge by examining comprehension of causal connections between
story events. According to representational theories of text or story
comprehension, coherent comprehension requires knowledge both
of individual ideas and events and of relations among those ideas
or events (e.g., Stein & Glenn, 1979; Trabasso & van den Broek,
1985). In particular, comprehending or inferring the causes of a
given event and the effects of that event on subsequent events (i.e.,
the causal relations between events) may be particularly important
to coherent comprehension of a narrative (e.g., van den Broek,
1990). In a study investigating free recall of audiotaped stories,
Tannock, Purvis, and Schachar (1993) found that boys with
ADHD have particular difficulty, relative to comparison boys, in
producing organized, cohesive retellings of narratives. In addition,
a replication and extension of Tannock et al.'s procedures (Lorch
et al., 1999) indicates that the number of causal relations a given
event has to other events predicts free recall among children with
ADHD and comparison children, but the relation is weaker for
children with ADHD. Thus, relative to their nonreferred peers,
children with ADHD benefit less from a story's causal structure in
their recall of story events. Consistent with ~ese effects on recall,
Milch-Reich, Campbell, Pelham, Connelly, and Geva (1999)
found that, relative to comparison children, children with ADHD
included fewer causal relations when telling a story represented by
a series of pictures.
The two studies presented here were designed to explore further
how children with ADHD use causal structure in their understand-
ing and recall of information. In addition, use of the television
methodology, including the manipulation of viewing condition
(i.e., toys present vs. toys absent), allowed us to investigate
whether any group differences in understanding causal connec-
tions relate to variations in visual attention to the television. In
Study 1, this was initially addressed by randomly assigning chil-
dren to view programming involving a primarily didactic presen-
tation of information with little story structure (i.e., "3-2-1 Con-
tact") or programming that incorporates a narrative structure (i.e.,
the situation comedy "Growing Pains"). In addition, follow-up
analyses examined differences in group performance on questions
judged to test factual information compared with questions testing
knowledge of causal relations between events. On the basis of the
results of Study 1, Study 2 was designed as a more explicit
comparison of group differences in children's understanding of
causal relations and how these differences may be influenced by
variations in visual attention. As such, all children viewed pro-
grams with a clear narrative structure, and questions were specif-
ically written to test memory for factual events or understanding of
causal relations between events.
The participants were 40 boys with ADHD and a comparison group
of 52 nonreferred boys, all ranging in age from 7 to 12 years. Approxi-
TELEVISION STORY COMPREHENSION AND ADHD
mately 94% of each group was Caucasian; the remaining boys were
Because the boys in this study were recruited before the publication of
the Diagnostic and Statistical Manual of Mental Disorders (4th edition;
DSM-IV; American Psychiatric Association, t994), those with ADHD
were carefully selected to fulfill the DSM (3rd edition, revised; DSM-
Ill-R) criteria for ADHD. However, consistent with the current combined
type defined in DSM-IV, boys must have exhibited problems with both
inattention as well as hyperactivity and impulsivity. Boys who only exhib-
ited attention problems were not included in the study.l To be included in
the study, boys with ADHD had to pass three separate screening phases.
In Phase l, all boys who were referred to a child psychiatry clinic and
received a diagnosis of ADHD were identified. This clinic diagnosis was
made independent of the research study and merely generated the pool of
eligible participants. During the second screening phase, if parents had
indicated interest in the study, we reviewed the boys' clinic files in detail
to identify those who appeared appropriate for the study. Boys in the clinic
sample were excluded from participation in the study if their symptom
picture and history were not consistent with a diagnosis of ADHD, if their
IQ was less than 80, or if they were taking antidepressant medication or
medications that could not be discontinued for the study. Boys were not
excluded from the study because of the presence of comorbid diagnoses
such as oppositional defiant disorder or conduct disorder (CD).
Boys who passed the second screening phase were scheduled to partic-
ipate in the study. At this time, diagnoses were confu'med through the use
of mother ratings on the Abbreviated Conners Rating Scale (ACRS;
Goyette, Conners, & Ulrich, 1978), which at that time was a widely used
parent rating scale for identifying children with ADHD. In addition, the
boys must have had a receptive language IQ of 80 or greater on the
Peabody Picture Vocabulary Test-Revised (PPVT-R). Boys with ADHD
who were being treated with stimulant medication did not receive their
medication on the day of the study. This is considered an acceptable
washout period for stimulant medication and is the standard procedure in
studies involving children with ADHD. To ensure compliance with this
request, parents received a reminder telephone call the night before the
study, and the medication-free status was confirmed at the session.
The children in the comparison group were recruited through the schools
and through newspaper advertisements. On the basis of a telephone inter-
view with a parent, the boys were judged to be free of learning and
behavior problems. The absence of behavioral problems associated with
ADHD was confirmed through the parental ratings on the ACRS. All boys
were paid $10 for their participation.
With regard to demographic data, the ADHD and comparison groups did
not differ significantly with regard to age (Ms = 120.7 and 121.6 months,
respectively), t(90) = .37, p > .05, or receptive language IQ, as measured
by the PPVT-R (Ms = 106 and 110, respectively), t(89) = 1.19, p > .05.
As expected, the boys with ADHD were rated significantly higher than the
comparison group on the parent.version of the ACRS (Ms = 18.2 and 5.5,
respectively), t(90) = 16.6, p < .001.
All boys viewed two 23-min television programs. Half of the boys
viewed two comedies ("Growing Pains"; Sullivan, Marshall, & Guntzel-
man, 1986), and the other half viewed two educational shows ("3-2-1
Contact"; 3-2-1 Contact, 1984). Both "Growing Pains" programs were
complete episodes from the second season of the program, with commer-
cials removed. In each program, the plot focused on the children in the
family. Each "3-2-1 Contact" program consisted of three segments that
were edited together. One segment in each tape ("The Bloodhound Gang")
was a detective story in which the child and teenage characters solve a
mystery using scientific information and logical reasoning. The other two
segments in each tape focused on the characteristics and behaviors of
different animals (otters and bats on one tape; the coypu and the rhinoceros
on the other). Each boy viewed one program with toys present and the other
program with no toys in the room. Order of viewing conditions and
assignment of programs to viewing condition were counterbalanced. The
toys included a remote-controlled car, a Transformer robot, an Etch-a-
Sketch, a basketball and hoop, and a hand-held video game.
The procedures followed those used by Landau et al. (1992). Before
each program, each boy was seated at a table. For the toys-absent condi-
tion, there was nothing on the table. For the toys-present condition, the toys
were placed on the table in a standard arrangement, with the basketball and
hoop on the floor nearby. The TV was placed on a cart at a height of
about 48 in. (121.92 cm), and the cart was located at a 450 angle from the
table. The camera was mounted in a comer on the opposite side of the room
from the TV. This arrangement ensured that boys had to make a distinct
head movement to view the program and that the direction of their gaze
was apparent on the videotaped record.
Each boy was given the following instructions: "There will be a TV
program coming on in a minute for you to watch." (For the toys-present
condition: "There are some toys here, too, and you can play with them if
you want while the TV program is on.") "When I come back into the room,
I'll ask you some questions about what you saw on TV." The examiner
then turned on the TV and VCR and, before leaving the room, said,
"Remember, I'll ask you some questions about what you saw when the
program is over."
While the TV program was shown, each boy was videotaped. An
observer viewing a monitor in a control room coded visual attention to the
television. The observer began the computer program simultaneously with
a signal preceding the program. This served to synchronize the computer
program with the TV program. The observer then pressed one key each
time the boy looked at the TV and another key each time he looked away.
This method produced a continuous record of onsets and offsets of visual
attention relative to the TV program. The primary measure of visual
attention derived from this record was percent visual attention to the
program. To understand better potential group differences in percent visual
attention, the number of discrete looks during the program also was coded.
Thus, it is possible to determine whether the groups may differ in the
frequency of looks and in the average length of looks at the screen.
Approximately 25% of the viewing sessions were recorded from the
videotapes to calculate interobserver reliability (Pearson r = .97).
After each program, the examiner entered the room, removed the toys
from the table, presented a still picture on the TV screen, and reintroduced
the characters from the program. (For "3-2-1 Contact," all three segments
was tested individually at the end of the program.) The test sequence began
with free recall, in which each boy was asked to tell as much as he could
remember from the program. When it was clear the child had stopped,
examiners offered two prompts ("Tell me some more from the story,"
"Think real hard and tell me something else from the story") before the
free-recaU test was terminated. Cued-recall testing followed, which con-
sisted of a structured series of questions. Questions followed the order of
presentation of information in the TV program and focused on central,
explicit content. The number of questions ranged from 21 to 26 because of
variations across programs in the amount of central content from which
questions could be derived.
1Consistent with theorizing by Barkley (1997), we conceptualize
ADHD as a disorder characterized primarily by problems in regulation and
self-control. Thus, children who only exhibit problems in attention appear
to have a different type of disorder. Such a conceptualization is consistent
with the research indicating that the inattentive subtype differs in important
ways from the combined subtype, including different family history data,
different gender ratios, and different concurrent and long-term correlates
324 LORCH ET AL.
All testing sessions were videotaped and audiotaped for later scoring. To
evaluate memory for the same information in free recall and cued recall,
free-recall protocols were scored for the information tested in the cued-
recall questions. That is, boys were given credit for each statement in free
recall that captured an answer to a cued-recall question. Thus, the range of
possible scores for free recall of a given program equaled the number of
cued-recall questions asked for that program. To estimate interrater reli-
ability for this coding, recall responses were scored twice for 28% of the
protocols. Percent agreement was 97% (K = .91).
In summary, dependent measures included two measures of visual
attention and two measures of recall of TV content. The principal measure
of attention, percent visual attention to the program, assessed amount of
viewing. The secondary measure, number of looks at the TV, assess~
shifts in attention, given the amount of viewing indicated by percent visual
attention. The two measures of recall of TV content were percent correct
in free recall and percent correct in cued recall.
All dependent measures were subjected to analyses of covari-
ance with group status (ADHD or comparison) and program
("Growing Pains" or "3-2-1 Contact") as between-participants
factors, viewing condition (toys present or toys absent) as a within-
participants factor, and age in months as a covariate. Age was
included as a covariate because of its well-documented relation to
measures of recall. Its use as a covariate was justified because the
assumption of the homogeneity of regression slopes was met.
Planned comparisons involving groups were performed with Bon-
ferroni corrections such that familywise error rate did not exceed
.05 (Myers, 1979).
tion to the television is presented in Table 1. There were significant
main effects for both group status and viewing condition. Com-
parison boys attended significantly longer (M = 73.7%) than boys
with ADHD (M = 62.2%), F(1, 87) = 11.89, p < .001. Boys
attended 94.6% of the time in the absence of toys but only 42.8%
of the time in the presence of toys, F(1, 87) = 321.12, p < .001.
These main effects are qualified by a significant Group x Viewing
condition interaction, F(1, 87) = 5.44, p < .05. In the absence
of toys, there was no difference between the amount of looking by
boys with ADHD (M = 92.1%) and comparison boys
(M = 96.6%), t(90) = 1.08, p > .10. In the presence of toys,
however, comparison boys
(M = 50.8%) than boys with ADHD (M = 32.3%), tOO) = 4.49,
p < .01. There were no other significant main effects or
Number of looks.
More looks occurred when toys were present
(M = 60.9, SD = 35,2) than when toys were absent (M = 18.5,
SD = 17.2), F(1, 87) = 126.56, p < .001. Looks also were more
frequent during the "Growing Pains" programs (M = 48.3,
SD = 20.7) than during the "3-2-1 Contact" programs (M = 32.1,
SD = 16.9), F(1, 87) = 16.62, p < .001. These effects are
qualified by a Program x Viewing condition interaction, F(1,
87) = 5.87, p < .05. In the absence of toys, there was no
significant difference between the frequency of looking during the
"Growing Pains" programs (M = 22.2, SD = 18.4) and the "3-2-1
Contact" programs (M = 15.1, SD = 15.5), t(90) = 1.32, p > .10.
In the presence of toys, however, looks were more frequent during
A summary of the means for percent atten-
attended significantly longer
Mean Percentage of Visual Attention and Mean Percentage
Correct in Free and Cued Recall in Study 1 as a Function of
Diagnostic Group, Program, and Viewing Condition
(n = 21)
(n = 18) Measure (n = t9) (n = 24)
Note. ADHD = attention deficit/hyperactivity disorder; GP = "'Growing
Pains"; 3-2-1 = "3-2-1 Contact."
the "Growing Pains" programs (M = 74.4, SD = 36.5) than dur-
ing the "3-2-1 Contact" programs (M = 49.12, SD = 29.7),
t(90) = 4.71, p < .01. There were no significant effects involving
Recall of TV Content
ble 1. Comparison boys (M = 24.8%) recalled more program
content than boys with ADHD (M = 15.2%), F(1, 87) = 13.09,
p < .001, and boys recalled more content from the "Growing
Pains" programs (M = 26.9%) than from the "3-2-1 Contact"
programs (M = 15.1%), F(1, 87) = 20.86, p < .001. There was a
significant Group X Program interaction, F(1, 87) = 3.99, p <
.05. For "3-2-1 Contact," the recall of boys with ADHD
(M = 11.9%) and comparison boys (M = 17.5%) did not differ,
t(47) = 1.53, p > .10; however, comparison boys (M = 33.3%)
recalled significantly more of the "Growing Pains" content than
boys with ADHD (M = 18.8%), t(41) = 3.95, p < .05. To
determine whether any of the group difference in free recall was
related to variations in visual attention, free-recall performance
was reanalyzed with visual attention as a covariate: Because of a
lack of variation in visual attention in the toys-absent condition,
this analysis only included the toys-present condition. When ana-
lyzed in this fashion, the main effect for group, F(1, 86) = 12.55,
p < .01, and the Group x Program interaction each remained
significant, F(1, 86) = 7.86, p < .01.
Free-recall performance is summarized in Ta-
TELEVISION STORY COMPREHENSION AND ADHD 325
Cued recall. Cued-recall performance is summarized in Ta-
ble 1. The main effects of all variables were significant. Compar-
ison boys (M = 65.3%) recalled more than boys with ADHD
(M = 56.6%), F(1, 87) = 7.26, p < .01. Additionally, boys
recalled more in the absence of toys (M = 67.6%) than in the
presence of toys (M = 55.4%), F(1, 87) = 56.27, p < .001, and
recalled more content from the "Growing Pains" programs
(M = 74.2%) than from the "3-2-1 Contact" programs
(M = 50.3%), F(1, 87) = 58.44, p < .001. Further, group and
viewing condition interacted, F(1, 87) = 4.57, p < .05, such that
recall of boys with ADHD (M = 64.7%) and comparison boys
(M = 69.8%) did not differ significantly when toys were absent,
t(90) = 2.20, p > .05, but comparison boys (M = 60.7%) recalled
more than boys with ADHD (M = 48.5%) when toys were present,
t(90) = 5.28, p < .01. To determine whether differences in visual
attention account for any of the group difference in cued recall
when toys were present, cued-recall performance in the toys-
present condition was reanalyzed with visual attention as a covari-
ate. When analyzed in this fashion, the group difference no longer
reached significance, F(1, 86) = 3.12, p < .10.
Although the cued-recall performance of boys with ADHD was
commensurate with their visual attention when toys were present,
such a difference between the ADHD and comparison groups is
not consistent with previous results (Landau et al., 1992; Lorch,
Milich, et al., 1987). A possible reason for this discrepancy may be
related to the kinds of questions included in cued-recall testing.
Examination of the questions used across the studies suggests a
potentially important variable. Some questions tested discrete,
factual pieces of information or single events (e.g., "What does a
bat feed on?" "What did Ben buy for $5?" or "what" questions),
whereas others tested causal connections between events or related
pieces of information (e.g., "Why can't humans hear the sounds
that bats make?" "Why does Mike need the magic rock?" or "why"
questions). Whereas the earlier studies tested primarily for the
recall of discrete, factual information, in Study 1 a much higher
proportion of the questions tested causal connections between
ideas or events. It is possible that achieving a cohesive understand-
ing of relations among events or ideas was more difficult for boys
with ADHD than comparison boys. Thus, the greater proportion of
why questions in Study 1 than in earlier studies may underlie the
poorer cued-recall performance of boys with ADHD in this study.
To explore this possibility, separate analyses of performance on
factual and why questions were performed (omitting one show for
which less than 10% of the questions were why questions). Con-
sistent with the overall result in the absence of toys, performance
of boys with ADHD and comparison boys did not differ signifi-
cantly either for factual (Ms = 61.0% and 67.6%, respectively),
t(70) = 1.32, p > .10, or why questions (Ms = 54.5% and 64.1%,
respectively), t(70) = 1.43, p > .10. In the presence of toys, boys
with ADHD and comparison boys did not differ significantly
for factual questions (Ms = 50.0% and 57.4%, respectively),
t(67) = 1.28, p > .10, replicating previous results (Landau et al.,
1992; Lorch, Milich, et al., 1987) with predominantly factual
questions. However, comparison boys correctly answered signifi-
cantly more why questions (M = 52.5%) than did boys with
ADHD (M = 37.8%), t(67) = 2.17, p < .05.
The visual attention results from Study 1 replicate those of
Landau et al. (1992), but with more lengthy and varied program-
ming. In the absence of a competing activity (i.e., toy play), boys
with ADHD and comparison boys were equally likely to sustain
attention to the television. The presence of toys reduced visual
attention to the television for all boys, but did so to a greater extent
for boys with ADHD than for comparison boys. These findings
suggest that boys with ADHD are capable of sustaining attention
to television for a relatively long period of time but are more likely
than comparison boys to become distracted or engaged by appeal-
ing alternative activities if these are available.
In terms of the'recaU data, differences between the two groups
varied, depending on both the program type and the testing pro-
cedure used. In free recall, comparison boys performed better than
boys with ADHD but only for the situation comedies. This pattern
of performance may reflect the fact that a narrative structure is
present to a much greater extent in the "Growing Pains" shows
than in "3-2-1 Contact." Comparison boys may have been better
than boys with ADHD at making effective use of the stronger
narrative structure in "Growing Pains" to guide their retellings of
In contrast to the results of the earlier television studies, the
cued-recall performance of comparison boys was significantly
superior to that of boys with ADHD. However, the results of the
exploratory analyses suggest a possible resolution of the discrep-
ancy in findings. Despite lower levels of visual attention of boys
with ADHD than comparison boys when toys were present, boys
with ADHD and comparison boys were able to recall a similar
amount of factual information. The decreased visual attention of
boys with ADHD in the presence of toys, however, seemed to
interfere with a more integrated understanding of the television
programming, as shown by poorer performance on questions that
tested understanding of causal connections. This interpretation is a
preliminary one, however, based on unsystematically selected
questions from Study 1 and including some programming that did
not have a narrative structure. To address these issues more di-
rectly, in Study 2 we only included programming with a narrative
structure, and we explicitly generated questions designed to test
factual information or causal connections between events. This
enabled us to compare the understanding of the causal connections
among story events by boys with ADHD and comparison boys and
to investigate how variations in visual attention may impact the
comprehension of causal connections.
The participants for Study 2 were 44 boys with ADHD and 59 nonre-
ferred comparison boys, all ranging in age from 7 to 12 years. None of
these boys had participated in Study 1. The boys with ADHD were
recruited in the same three-stage process as in Study 1, except that instead
of confirming the diagnosis with the ACRS, the ADHD diagnosis was
326 LORCH ET AL.
confirmed by parental reports on the Disruptive Behavior Disorder (DBD)
rating scale (Pelham, Gnagy, Greenslade, & Milich, 1992). The DBD
rating scale consisted of the verbatim DSM-III-R criteria for ADHD and
CD, presented in a rating scale format, with choices ranging from not at all
to very much.
The two groups of boys did not differ significantly in terms of age (Ms =
115.0 and 115.2 months), t(101) < 1, but the comparison boys had a
significantly higher PPVT-R receptive language score than the boys with
ADHD (Ms = 113.7 and 108.3, respectively), t(101) = 2.06,p < .05. This
difference was statistically controlled for in the analyses that follow. As
expected, boys with ADHD were rated significantly higher than compar-
ison boys on the DBD in terms of ADHD (Ms = 9.7 and 0.3, respectively),
t(101) = 16.1, p < .001, and conduct disorder (Ms = 0.9 and 0.0,
respectively), t(101) = 2.41, p < .01, symptomatology. Three of the boys
with ADHD (7%) and none of the comparison boys met diagnostic criteria
for conduct disorder. There were 6 (10%) African American boys in the
comparison group and 2 (5%) in the ADHD group, a difference that was
not statistically significant. None of the boys with ADHD received any
psychostimulant medication on the day of the study. All boys earned $I0
for their participation.
The measures of visual attention were the same as for Study 1:
percent visual attention to the TV and number of looks at the TV.
The measures of recall of TV content were percent correct in cued
recall for each of the three types of questions (factual, within-
episode connections, and between-episodes connections). Each
type of question was analyzed separately. All dependent measures
were subjected to analyses of covariance with group status (ADHD
or comparison) as a between-participants factor, viewing condition
(toys present or toys absent) as a within-participants factor, and
age and PPVT-R scores as covariates. However, because of vio-
lations of the assumption of homogeneity of the regression slopes,
PPVT-R scores could not be used as a covariate in the analyses of
the visual attention measures and age could not be used as a
covariate in the analyses of cued recall. Planned comparisons
involving groups were conducted with Bonferroni corrections such
that familywise error rate did not exceed .05 (Myers, 1979).
M1 boys viewed the two 23-min "Growing Pains" episodes used in
Study 1. Each boy viewed one program with toys present and the other
program with no toys in the room. Order of viewing conditions and
assignment of episodes to viewing condition were counterbalanced. The
selection of toys was the same as in Study 1.
The procedure was identical to that used in Study 1, with the exceptions
of modifications of the cued-recall testing. The cued-recall questions
consisted of factual questions (what questions) that tested recall of discrete
information and why questions that tested understanding of causal connec-
tions. The why questions were further divided into "within-episode" and
"between-episodes" questions (Trabasso, van den Broek,& Liu, 1988).
Story grammar and causal network analyses of stories define story epi-
sodes, in which each episode revolves around a particular goal (Stein &
Glenn, 1979; Trabasso & van den Broek, 1985). Most stories contain
multiple episodes, often hierarchically organized to reflect superordinate
and subordinate relations among goals and subgoals. Within-episode ques-
tions are those in which the answers are contained in the same episodes as
the connecting events referred to in the questions, whereas between-
episodes questions are those in which the answers are linked to episodes
relatively remote in time. Both types of why questions should require more
integration of program information than the factual questions, but it was
expected that the between-episodes questions would be more demanding
(van den Broek, 1989).
Questions followed the order of presentation of information in the TV
program, mixing the three types of questions. Questions tested 28 units of
information from one program and 31 units of information from the other
program. Across the two "Growing Pains" programs, the distribution of
questions was such that 25% of the information tested was factual, 39%
concerned within-episode connections, and the remaining 35% concerned
As in Study 1, free-recall protocols were scored for the information
tested in the cued-recall questions. It should be noted that to be credited
with free recall of information tested in a "why" question, the child's recall
protocol was required to contain the relevant causal connection between
events. As a consequence, free recall of these categories was quite low (less
than 10% in many cells). As such, free-recall results were uninformative
and are not presented in detail.
important findings of Study 1. Once again, comparison boys
attended significantly longer (M = 77.0%) than those with ADHD
(M = 70,1%), F(1, 99) = 5.32, p < .01. Attention averaged 95.6%
in the absence of toys but 52.5% in the presence of toys, F(1,
99) = 252.63, p < .001. As in Study 1, these main effects are
qualified by a significant Group X Viewing condition interaction,
F(1, 99) = 5.68, p < .05. In the absence of toys the amount of
looking by boys with ADHD (M = 95.5%, SD = 4.8) and
comparison boys (M = 95.8%, SD = 7.7) was virtually identical,
t(100) < 1, whereas in the presence of toys comparison boys
attended significantly longer (M = 58.3%, SD = 29.0) than boys
with ADHD (M = 44.8%, SD = 27.3), t(100) = 3.48, p < .01.
There were no other significant effects.
Number of looks.
As in Study 1, boys made more frequent
looks when toys were present (M = 85.6, SD = 51.0) than when
toys were absent (M = 20.9, SD = 16.0), F(1, 99) = 156.08, p <
.001. No other main effects or interactions were significant.
The results for percent attention replicate all
Recall of TV Content
Performance on the three types of cued-recall questions is
summarized in Table 2. For each type of question, boys answered
more questions correctly when in the toys-absent condition than in
the toys-present condition, Fs(1, 98) = 23.51 and 10,93, ps <
.001, and 5.88, p < .05, for factual, within-episode, and between-
episode questions, respectively. There was no significant differ-
ence between the ADHD and comparison groups for any type of
question, nor was there a significant Group x Viewing condition
interaction for factual or between-episode "why" questions. How-
ever, a significant Group x Viewing condition interaction was
observed for within-episode "why" questions, F(1, 98) = 4.05,
p < .05. There was no difference between the comparison boys
(M = 62.2%) and boys with ADHD (M = 59.5%) in the toys-
absent condition, t(100) < 1, but in the toys-present condition the
comparison boys (M = 59.7%) answered significantly more of the
within-episode questions than did those with ADHD (M = 47.2%),
t(100) = 4.33, p < .01. To determine whether differences in visual
TELEVISION STORY COMPREHENSION AND ADHD 327
Percentage Correct in Cued Recall in Study 2 as a Function of Diagnostic Group, Viewing
Condition, and Type of Question
Toys absent Toys present
episode Group Fact Fact
ADHD (n = 43)
Comparison (n = 57)
Note. ADHD = attention deficit/hyperactivity disorder; Fact = factual questions.
attention accounted for any of the group difference in cued recall
when toys were present, cued-recall performance in the toys-
present condition was reanalyzed with visual attention as a covari-
ate. When analyzed in this fashion, the group difference no longer
reached significance, F(1, 99) = 3.29, p < .10.
Surprisingly, the results for the between-episodes "why" ques-
tions differed from those for the within-episode "why" questions.
As shown by the mean performance levels, the between-episodes
questions are relatively demanding, but they produced no signifi-
cant group difference or Group × Viewing condition interaction.
One possible reason for this discrepancy may be that, despite the
relative difficulty of the between-episodes questions, they actually
may permit more compensation for decreased visual attention than
the within-episode questions. The between-episodes questions
concern temporally separate events, but events that are generally
important to the plot of the story. Therefore, these temporally
distant events are likely to have connections with other intervening
events that may support the content tested in a between-episodes
question (i.e., attention to any of these events may help a child to
answer the question). In contrast, within-episode questions con-
cern the relation between two events occurring close together in
time. Although these events also may be causally connected to
other events in the story, a child's comprehension of the particular,
local connection tested in a within-episode question may be more
dependent on visual attention to those events.
To explore this interpretation further, two types of follow-up
analyses were undertaken. For the first set of analyses, coders
unfamiliar with the purposes of the study determined the number
of times information needed to answer each cued-recall question
was presented. To do this, the coders used a complete audiovisual
script of each program; each script was parsed into individual units
of information, such that each unit represented a single event or
idea (see Lorch, Bellack, & Augsbach, 1987). For each question,
they recorded the number of units that contained information
enabling a correct answer. Pairs of coders resolved any discrep-
ancies in their judgments by discussion. Consistent with the inter-
pretation suggested previously, information enabling correct re-
sponses was presented less frequently (M = 3.57 units) for within-
episode "why" questions than for between-episode "why"
questions (M = 7.86 units), t(42) = 3.27, p < .01.
In the second set of analyses, correlations between recall per-
formance and percent attention during units of information en-
abling correct answers to questions were computed. Because of
restricted variability in percent attention in the toys-absent condi-
tion, correlations were computed only for the toys-present condi-
tion. Separate correlations were computed for each group and for
each type of question. Again consistent with the previous inter-
pretation above, visual attention of boys with ADHD was posi-
tively related to cued-recall performance on within-episode ques-
tions, r(42) = .47, p < .001, but not to performance on between-
episode questions, r(42) = .10. The difference in the magnitude of
the correlations was significant, Hotelling's t(41) = 2.95, p < .01.
For comparison boys, there were no significant correlations be-
tween visual attention and recall performance for any type of
The results of Studies 1 and 2, taken together with the earlier
research (Landau et al., 1992), lead to consistent conclusions about
visual attention to television and its relation to story recall among
boys with ADHD. Three sets of findings are of particular interest
in forming these conclusions. First, results for visual attention are
entirely consistent across the three studies. Both groups of boys
sustained high levels of visual attention to television in the absence
of toys, whereas the presence of toys reduced visual attention of
boys with ADHD to a greater degree than for comparison boys.
Second, also consistent across the three studies, the groups did not
differ significantly in cued recall of discrete, factual information,
regardless of the presence of toys during viewing. Third, differ-
ences in story comprehension of boys with ADHD and comparison
boys emerged when tasks tapped the use of story structure
(Study 1, free recall of narrative information) or the understanding
of specific causal relations between story events (Study 1, explor-
atory analyses of "why" questions; Study 2, within-episode "why"
One implication of these findings is that boys with ADHD are
capable of sustained attention, as shown in the toys-absent condi-
tion. Although the very high levels of visual attention in the
toys-absent condition in these studies may represent a ceiling
effect that could account for the lack of differences between the
two groups, there are a few points to consider that may make these
"ceiling effects" meaningful. First, it is striking and unique to the
328 LORCH ET AL.
research literature that children with ADHD can sustain attention
for 23 min to any task, regardless of the characteristics of the task.
Second, as shown by the cued-recall results, the high attention of
boys with ADHD when toys were absent does not seem to repre-
sent an instance of passively staring at the television without
processing information. Across the three studies and regardless of
the type of question, the cued-recall performance by boys with
ADHD in the toys-absent viewing condition did not differ from
that of comparison boys.
In contrast, the findings for the toys-present condition suggest
that boys with ADHD and comparison boys may differ in their
allocation of attention to television in the presence of a competing
and highly engaging activity, with toys reducing visual attention of
boys with ADHD more than for comparison boys. The differential
reductions in visual attention did not lead to group differences on
factual questions but did interfere with performance on questions
testing specific causal relations. The impact of visual attention on
the recall performance of boys with ADHD is substantiated further
by the results from both studies that group differences in the
toys-present condition are no longer significant when differences
in attention are controlled. Interestingly, when toys were absent,
the two groups did not differ in the proportion of within-episode
questions answered correctly. This suggests that boys with ADHD
are not deficient in the skills necessary to comprehend causal
connections in the story if they are able to focus their attention
entirely on the television program. Their grasp of causal connec-
tions appears to be more fragile than that of comparison boys, who
showed no decrement in recall of within-episode causal connec-
tions when toys were present during viewing.
Further insight into the nature of the impact of the greater
reduction in visual attention on story comprehension may be
obtained by also considering results obtained for the number of
looks at and away from the television. In each of the studies, the
lower levels of visual attention by boys with ADHD when toys
were present is not associated with any difference in the frequency
of looks at and away from the television. Therefore, the lower
levels of visual attention among boys with ADHD must be due to
looks that are shorter in average length. Research with nonreferred
children and adults has indicated that, relative to short looks at the
television, periods of sustained looking are associated with greater
cognitive engagement with, or deeper processing of, a televised
story (Anderson, Choi, & Lorch, 1987; Bums & Anderson, 1993;
Lorch & Castle, 1997). Specifically, longer looks are associated
with less distractibility to extraneous stimuli (Anderson et al.,
1987), slower response times to a secondary probe (Lorch &
Castle, 1997), and better recognition memory than for content
presented during shorter looks (Burns & Anderson, 1993). The
patterns of shorter looks among boys with ADHD when toys are
present may indicate that, when attention is divided between
television and toy play, boys with ADHD tend not to be as engaged
with the story at any given moment as comparison boys. The
attention of boys with ADHD may be sufficient for the encoding
of discrete events; however, reduced sustained engagement with
the material may impede construction of a more coherent, con-
nected story representation. If comparison boys sustain more con-
tinuous cognitive processing than boys with ADHD, they would be
more likely to maintain the causal thread of the story, encoding
more connections or more effectively inferring connections during
questioning. Future research should more directly address the
degree to which children with ADHD, compared with nor, referred
children, sustain cognitive engagement in the presence of compet-
An alternative, but not entirely unrelated, framework for inter-
preting the patterns of visual attention and recall across viewing
conditions concerns what Ceci and Tishman (1984) described as
diffuse attention among children with ADHD. In their view, chil-
dren with ADHD are more likely than comparison children to
distribute their attention broadly across available information and
activities. Ceci and Tishman (1984) found that when processing
demands of stimuli defined as central were relatively low (e.g.,
ample time, familiar stimuli), children with ADHD were able to
process both central and incidental stimuli, performing as well as
or better than comparison children on recognition tasks. However,
when processing demands were high and children with ADHD
continued to distribute their attention broadly, their performance
on the central task was adversely affected relative to comparison
children. Our findings for cued recall of factual information in the
toys-present condition are consistent with Ceci and Tishman's
findings for a task with low processing demands. Although the
boys with ADHD shifted more of their attention from television to
toys than did comparison boys, the boys with ADHD were still
able to encode enough of the television programs to answer a
similar number of factual questions correctly. Similarly, although
between-episode why questions were more demanding, the repe-
tition of relevant information may have reduced the impact of
visual attention on performance on these questions. In contrast, the
processing demands of the why questions identified in Study 1 and
the within-episode why questions used in Study 2 were such that
a broad distribution of attention by boys with ADHD would
interfere with recall of the specific relational links tested in these
questions. Thus, the consequences of more diffuse attention seem
to be situation or task specific: Children with ADHD may perform
similarly to comparison children in situations in which a broad
distribution of attention is adequate to meet task demands, but
performance of children with ADHD may be more likely to suffer
when focused, specific attention to more complicated information
is required. In a related vein, O'Neill and Douglas (1991) dis-
cussed tasks for which the "quick and cursory" approach thought
to characterize children with ADHD can be successful, but also
noted that such an approach may break down when increased
effort or strategy use is required. This latter point also may relate
to the specific pattern of free-recall differences between the groups
found in Study 1.
There are several limitations of the current studies. First, only
boys participated in the studies because of the much greater
prevalence of ADHD among boys. Some evidence suggests that
boys and girls with ADHD may differ in their cognitive processing
(Gaub & Carlson, 1997; Lorch et al., 1999), although this question
needs much more investigation. Second, although some evidence
suggests that the presence of comorbid learning disabilities (Pen-
nington et al., 1993; Tannock et al., 1993) or conduct disorder
(Halperin et al., 1988) may moderate the cognitive processing of
children with ADHD, analyses examining the effects of comorbid
diagnoses could not be undertaken in the present studies. Third,
although, as expected, between-episode why questions were most
difficult overall, we also had expected group differences on these
questions. Our data suggest that the more frequent presentation of
information supporting answers to these question may explain the
TELEVISION STORY COMPREHENSION AND ADHD
lack of group differences, Nevertheless, future research should
continue to explore the possibility of group differences in the
understanding of different types of causal relations within stories.
Another limitation is that we tested for recall of information
presented both visually and auditorily but only measured chil-
dren's visual attention to television. It is important to note that
modality of presentation (audio, visual, or audiovisual) did not
vary for the different types of questions used in Study 2. Never-
theless, future research should address more systematically the
processing of information presented in the different modalities. A
final limitation is that only recall measures were used to assess
story comprehension. Valuable complementary information about
how children with ADHD form a story representation can be
gained from measures of on-line processing (see Milch-Reich et
In summary, the results of these studies expand understanding of
the story comprehension of boys with ADHD and the relation of
visual attention to the comprehension of televised stories. The
important differences between boys with ADHD and comparison
boys appear to concern more fragmented or diffuse attention
among boys with ADHD, which in turn is related to group differ-
ences in the use of story structure and in the creation of relational
links between ideas and events. With few exceptions (Lorch et al.,
1999; Milch-Reich et al., 1999; O'Neill & Douglas, 1991; Tan-
nocket al., 1993), there has been little attention to story compre-
hension when examining the information processing of children
with ADHD. An examination of the specific differences in story
processing between children with ADHD and comparison children
is relevant to understanding both the academic performance
(O'Neill & Douglas, 1991; Tannock et al., 1993) and the social
relationships (Milch-Reich et al,, 1999) of children with ADHD. In
both these domains, the accurate comprehension of cause-and-
effect relations appears to be a vital skill.
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Received July 13, 1998
Revision received October 15, 1999
Accepted October 15, 1999 "
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