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Narrative Intervention A School-Based Counseling Strategy for Students With Attention-Deficit/Hyperactivity Disorder


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This article describes a group narrative intervention for improving the behavior of 8- to 11-year-old children with attention-deficit/hyperactivity disorder at home and school.
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Intervention in School and Clinic
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DOI: 10.1177/1053451212472728
2013 48: 307 originally published online 30 January 2013Intervention in School and Clinic
Khosrow Kamali and Majid Yoosefi Looyeh
Attention-Deficit/Hyperactivity Disorder
Narrative Intervention: A School-Based Counseling Strategy for Students With
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Theresa Earles-Vollrath, Associate Editor
This article describes a group narrative intervention for improving the behavior of 8- to 11-year-old children with attention-
deficit/hyperactivity disorder at home and school.
narrative intervention, ADHD, school counseling
ion in School and ClinicKamali and Yoosefi Looyeh
© Hammill Institute on Disabilities 2013
Reprints and permission:
1UMCAS University of Malaya, Kuala Lumpur, Malaysia
2Tehran Islamic Azad University, Tehran, Iran
Corresponding author:
Khosrow Kamali, UMCAS Faculty of Medicine, University of Malaya,
Kuala Lumpur, Malaysia 59100.
Narrative Intervention: A School-Based
Counseling Strategy for Students With
Attention-Deficit/Hyperactivity Disorder
Khosrow Kamali, PhD1 and Majid Yoosefi Looyeh, PhD1,2
Children with attention-deficit/hyperactivity disorder
(ADHD) exhibit behaviors that affect their academic perfor-
mance, interactions with others, and ability to handle routine
tasks at home and school. Research has indicated that chil-
dren with ADHD experience feelings of loneliness and iso-
lation, low self-esteem, shyness, misunderstandings, being
different, frustrations and verbal arguments with parents and
siblings, being left out of school activities, interpersonal dif-
ficulties with peers, and the stigma of having a disorder.
Over time they develop a perception of themselves as prob-
lem children, centered on being different from others,
308 Intervention in School and Clinic 48(5)
troublesome for family and teachers, disliked by peers, and
powerless to manage impulsive behaviors (Kendall, Hatton,
Beckett, & Leo, 2003; Krueger & Kendall, 2001; Shattell,
Bartlett, & Rowe, 2008). Such self-defeating and disabling
narratives compound the behavioral problems that limit self-
understanding and flexibility in self-management.
There is an abundance of literature on the medical and
behavioral management of children with ADHD (MTA
Cooperative Group, 2004; Toplak, Connors, Shuster,
Knezevic, & Parks, 2008; Waschbusch & Hill, 2003). With
the exception of some cognitive behavioral therapies, far
less attention has been paid to interventions that can help to
change unhelpful and self-defeating perceptions and pro-
duce change in behavior. Using language, stories, and nar-
rative questioning, narrative therapy provides a framework
for identifying unhealthy narratives and envisioning and
developing self-enabling narratives that foster effective
self-management (Freeman & Combs, 1996). This column
presents a group narrative intervention for improving the
behavior of preadolescent children with ADHD that can be
implemented in school settings.
Theoretical Foundation
Narrative therapy holds that people attribute meaning to the
experience of events in their lives, which over time shapes
their perceptions and the stories they construct about who
they are. The stories, or narratives, reflect their identities
and how they live their lives. Some narratives have positive
influences, and others have negative influences on the way
people behave and manage themselves. Certain negative
life experiences or the onset of psychological disorders can
produce self-defeating and dysfunctional narratives that
sustain the problems (Richert, 2006).
A major premise of narrative therapy is that the person is
not the problem. Rather, the problem is acknowledged as the
problem, thereby distancing or externalizing it from the per-
son. The externalization and objectification of problems are
effective tools, especially for children, to better understand
their dominant problem-saturated narratives and learn to
deal with problems rather than view them as intrinsic to their
being. Externalizing is also applied to potential solutions, or
initiatives, which include thoughts, feelings, or actions that
do not support and sustain problems. For example, initia-
tives in children with ADHD may include an intention to not
blurt out answers before questions are completed, not inter-
rupt conversations, and to coordinate physical movements
with mental imagination. Narrative therapists assume that
people are able, and have the competency, to construct alter-
native narratives and change their relationship with problems.
The process is nonblaming and fosters a sense of control over
problems and responsibility for self-management (White &
Epston, 1990).
White (2007) clarified the process of narrative therapy,
technically known as the scaffolding conversation map, to
indicate what changes would be expected in a successful
session and how it should be applied to achieve the desired
outcome. In the course of narrative therapy, client and ther-
apist work together in a series of steps to (a) identify, name,
and characterize problems and potential solutions; (b) eval-
uate the consequences of problems or potential solutions;
(c) explore the thinking behind this evaluation and the effect
of potential solutions on the clients’ day-to-day experi-
ences; and (d) determine how to take responsibility for put-
ting intentions and plans for managing problems into action.
The sequential process of narrative intervention has been
the subject of empirical validation (Ramey, Tarulli, Frijters,
& Fisher, 2009).
There is an abundance of writing by practitioners who
have attested to the effectiveness of narrative techniques for
addressing the needs of children with emotional and behav-
ioral problems (e.g., Bennett, 2008; Vetere & Dowling,
2005). This literature includes a large number of case studies
that have demonstrated the efficacy of narrative therapy in
dealing with a variety of problems in children. For example,
narrative techniques have been effective in (a) developing
positive, empowering identities in children (DeSocio, 2005);
(b) helping children of parents with affective disorders
(Focht & Beardslee, 1996); (c) working with children with
hearing impairment (Furlonger, 1999); (d) healing children
who have experienced sexual abuse (McKenzie, 2005); and
(e) increasing the ability to accept nurturing and care in chil-
dren with early childhood maltreatment (May, 2005).
Sheibani, Yoosefi Looyeh, and Delavar (2007) applied
narrative therapy to a small group of girls ages 10 to 11
years with depression. Using a pretest-posttest–only design
and behavioral symptoms checklists, they demonstrated a
significant reduction in symptoms as reported by parents
and teachers. Yoosefi Looyeh and Matin (2006) imple-
mented a group narrative intervention for 20 boys and girls
age 11 years with learning disabilities. The children were
randomly assigned to intervention and control groups. The
intervention group displayed significant improvements in
coping strategies, such as problem solving, stress manage-
ment, dealing with negative emotions, and improved self-
awareness. Yoosefi Looyeh, Kamali, and Ashrafpouri (in
press) used a similar group narrative protocol for 30 boys
ages 10 to 11 years with oppositional defiant disorder. Boys
in the intervention group received 15 sessions of 90 minutes
of narrative therapy twice weekly. Parents and teachers
reported significant improvements in the behavior of the
children in the intervention group but no improvement in
the behavior of the wait-list group.
Group Narrative Intervention
for Children With ADHD
Yoosefi Looyeh and Kamali (2012) implemented a group
narrative intervention for preadolescent girls with ADHD
in a school setting. Children in the intervention groups
Kamali and Yoosefi Looyeh 309
attended 12 sessions of approximately 60 minutes of narra-
tive therapy twice weekly, with homework between ses-
sions. Children who participated in the narrative intervention
demonstrated significant improvements in school-related
behaviors as reported by teachers. The results suggested
that group narrative intervention is an effective technique
for improving the behavior of children with ADHD. In the
study, a school counselor with training in narrative tech-
niques facilitated the sessions. Teachers played a minor role
as cofacilitators. Experience has indicated that school coun-
selors, social workers, and special education teachers who
are familiar with narrative therapy can facilitate the ses-
sions. To assist facilitators, we describe the process of the
narrative intervention, group activities and sessions that are
used, the focus of the group conversations, and expected
outcomes in this article (see Note 1).
Table 1 presents the steps in implementing narrative inter-
ventions. Group activities, storytelling, and story making
provide a medium for facilitating the intervention. Stories
narrated by the facilitator depict situations similar to the
day-to-day experiences of children with ADHD at home,
school, or other settings. The scenarios describe the behav-
ior of the story’s actors, consequences, how they feel and
think about themselves, and how others react to them. The
stories allow the children to observe their problems and
potential solutions from a distance, as somewhat indepen-
dent observers. The stories told by the children allow them
to communicate and project their problem-saturated narra-
tives or to construct new narratives.
The intervention starts with (a) guiding the children to
describe and construct definitions of the problems based on
their own experience and (b) exploring the relationships
among problems, solutions, and consequences. Initially, the
aim is to develop an understanding of why a problem is a
problem, not what caused the problem. As the sessions
progress, the children reflect on whether they want the
problem in their lives, what would happen if the problem
were to continue to exist, and, alternatively, what would
happen if they had control over the problem by behaving
differently. The focus then shifts to identifying alternative
behaviors, the effects on their lives, and what they can do to
manage problems differently than they have in the past.
Group Activities
Six group activities used in the sessions are briefly
described. These activities are based on or adapted from the
comprehensive collection of play therapy activities com-
piled by Kaduson and Schaefer (1998). In most sessions,
more than one activity is used to provide variety and stimu-
late interest in the group interactions. Some activities are
repeated in more than one session with different stories and
characters but were focused on either different ADHD-
related behaviors or particular steps of the narrative inter-
vention. In the first few sessions the focus was on the
behavior of the characters in the stories. As the sessions
progressed, the children told stories based on their own
The feeling word game. This group activity, used in Ses-
sions 1 through 3, is aimed at increasing emotional self-
awareness and expressing feelings and thoughts associated
with emotions. Each child is given a set of cards with names
of various emotions (e.g., happy, sad, angry) and a box of
tokens. After a demonstration, they take turns in making up
and telling stories. When an emotion is expressed in the
story, they name and describe the emotion and place a num-
ber of tokens corresponding to the intensity of the emotion
on the relevant card in front of them. In the second and third
sessions they are encouraged to tell stories based on their
own experiences at home or school, and they begin to
express their ADHD narratives and how they feel.
Metaphors for calmness. Metaphors for calmness, used in
Sessions 2, 3, and 6, are aimed at identifying and naming
impulsive behaviors, and creating awareness of conse-
quences of impulsivity and how to manage it. The facilitator
tells a story in which a character exhibits impulsive behav-
iors and how it affects the character’s interactions with oth-
ers. In Session 2 the conversation is focused on naming and
Table 1. Steps in Narrative Intervention and Outcomes.
Step Narrative Conversations and Outcomes
Identify, name, and
problems and
Children identify, describe, and construct
their own definition of problems;
explore other people’s perceptions;
begin to understand the power the
problem exerts over them
Explore the effects
of problems or
Understand why a problem is a problem;
identify the relationship between
the problem and its influence on the
children’s lives; explore the effects of
alternative solutions
Do the children want the problem in
their lives? What would happen if a
problem were to continue to exist?
Alternatively, what would happen if they
had control over the problem?
Construct new
Explore desirability of alternative
solutions; their effects on the children’s
lives; what they can do to manage a
problem differently
Develop plans
and take
responsibility for
Describe solutions identified; think
through how to put solutions into
action; describe positive effects of
having control over problems and its
influence on their lives
310 Intervention in School and Clinic 48(5)
describing the behavior of the characters in the story. In
Sessions 3 and 6 the children describe similar experiences
they have had, how they felt about the way others responded,
and the consequences of behaving differently from the way
they usually deal with similar situations.
The scarf story. This activity, used in Sessions 3, 4, 5, 6,
and 8, is aimed at recognizing the importance of nonverbal
behaviors and coordination of physical movements with ver-
bal imagination. The children take turns at moving under a
large scarf held by the group. The facilitator tells a story with
a character who engages in various physical movements.
Following instructions, at certain points in the story the scarf
is raised and the child under the scarf mimics and acts out
movements of the story’s character as it is being narrated by
the facilitator. Initially the focus is on describing difficulties
the child has in following movements of the character in the
story. In Sessions 4 through 6 the child under the scarf is
asked to act out the movements and at the same time describe
what the story’s character may be feeling and thinking. In
Session 8, the children take turns and replace the facilitator
as the storyteller. Each session ends with a discussion about
identifying and characterizing difficulties the children have
in synchronizing actions with mental images of behaviors
and the consequences of exercising self-control.
Metaphors for attentiveness. This activity, used in Ses-
sions 4, 5, 9, and 10, is aimed at increasing understanding of
inattention and distractibility. The facilitator tells a story
that contains a character who exhibits symptoms of atten-
tion-deficit disorder (e.g., distractibility, trouble listening or
following directions, forgetfulness, disorganization). Each
child is given 10 cards containing words and pictures with
references to the events in the story. When an event in the
story is mentioned, the children are expected to pick up and
raise the relevant card. The conversation centers on the chil-
dren who miss raising the correct card on time, identifying
and describing inattention and its consequences, and search-
ing for possible solutions for managing it.
Storytelling with objects. This activity, used in Sessions 7,
10, 11, and 12, is aimed at internalizing solutions and devel-
oping expertise in self-management through identifying and
characterizing alternative solutions to problems. The children
take turns and choose one of five objects to tell a story in
which a character exhibits problems at home or school and
how effectively he or she deals with the problems. In Ses-
sions 7 and 10 the conversation is focused on the feelings,
beliefs, and thinking of the actor in the story, and the thought
process the actor goes through to evaluate various solutions
and the consequences of managing problems. In Sessions 11
and 12 the emphasis is on what they would do if they experi-
ence similar problems, why they would choose a particular
solution, and their assessment of its effects on their lives.
Metaphors and fairy tale. Metaphors and fairy tale, used
in Sessions 7, 8, 11, and 12, is aimed at helping the children
develop plans and take responsibility for self-management.
The facilitator tells a story with a character who displays
selected ADHD symptoms. The character in the story
reflects on and evaluates various solutions for dealing with
the problem. The story ends with the character feeling good
about successfully having identified and responded with
solutions that resulted in positive consequences and affir-
mative feedback from others. In Sessions 7 and 8 the chil-
dren mentally rehearse the process of choosing and
executing solutions. In Sessions 11 and 12 the conversation
places more emphasis on describing the positive conse-
quences of adopting alternative solutions and why the alter-
native behaviors are desirable.
The choice of homework and the debriefing conversations
parallel and support specific outcomes expected in succes-
sive sessions (see Table 2). Homework allows the children
to reflect on and develop awareness of problems at home or
school, ask for feedback, and share their experiences with
other children in the group. Homework may be assigned to
the group or individuals, depending on the content of a ses-
sion and the emphasis the facilitator may wish to place on
specific problems, solutions, or steps in the narrative inter-
vention to achieve the desired outcome. It is helpful to
provide each child with a pocket-size booklet with an
attached pen for recording assignments and keeping a diary
of behaviors, events, feelings, and thoughts he or she
wishes to discuss with the group.
The intervention described in this article offers a practical
approach for improving the behavior of children ages 8 to
11 years with ADHD. Groups of three to four children with
comparable levels of communication skills and two weekly
60-minute sessions are suitable for working with children
with ADHD. Larger groups and longer sessions are likely
to divert attention from the group conversations. Our expe-
rience has indicated that some parents are more willing to
support the intervention when it is offered in a school set-
ting, viewing it as part of their children’s education. This
may be a salient issue for girls from certain cultural back-
grounds who may experience a greater stigma from being
labeled a “problem child” and receiving “treatment” in a
clinic setting.
Narrative intervention offers a structured process for
guiding children to identify and describe their problems and
how they typically deal with them, and also incrementally
in manageable steps to shift their narratives to how they
may effectively manage their problems. The medium of
Kamali and Yoosefi Looyeh 311
storytelling/story making provides a safe and entertaining
environment for engaging the children in group conversa-
tions. As the sessions progress, the children are able to dif-
ferentiate between ADHD and non-ADHD behaviors and
consequences, explore alternative solutions with positive
consequences, construct new narratives, and develop the
self-management skills they need to behave differently.
During the last few sessions, the conversation is focused on
developing plans and taking responsibility for self-manage-
ment. The children describe solutions they have identified,
how they would put them into action, and the positive
effects of having control over problems (Yoosefi Looyeh &
Kamali, 2012).
Following the narrative approach, the facilitator does not
offer solutions or persuade the children to adopt a particular
course of action. Rather, the facilitator guides the children
to explore, identify, evaluate, and pursue solutions on their
own initiative. This plays an important role in internalizing
new narratives and increasing the potential for behaving
differently. The children are viewed as being able to define
their problems, envision and characterize solutions, and
take responsibility for self-management. Consequently, in
the sessions they are actively involved in defining problems
based on their own experiences, developing awareness of
the association between problems and solutions and conse-
quences in terms they understand, and evaluating and
choosing solutions they are able to implement. The result is
a newfound sense of personal agency, a sense that they can
regulate and manage their behavior (White, 2007).
In a group setting the narrative process is aided by shar-
ing stories about the children’s experience of ADHD; the
reactions of parents, teachers, and peers; and the successes
or failures of various initiatives and the resulting effects on
their lives. Often the behavior of the children in the sessions
reflects their ADHD symptoms, such as interrupting others,
not listening, and not talking excessively. A sign that the
intervention is successful is when the children begin to iden-
tify and remind each other of inappropriate behaviors and
the consequences and to offer solutions without prompting.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
1. An outline of the sessions, a partial transcript of a group narra-
tive session, and additional examples of homework are avail-
able from the corresponding author.
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explanation and practice issues. Journal of Child and Adoles-
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Table 2. Examples of Homework.
Session Assignment Outcome
1 Make a list of situations
that made you worry,
fearful, angry, sad, or
happy and what you did
after having these feelings.
Emotional self-
awareness; identify
feelings; relate feelings
to behaviors
4 Ask your brothers/sisters
(parents or teachers)
what you do that bothers
them and how they feel
about it.
consequences of
problem behaviors;
how problems affect
11 Ask your parents changes
they observe in you in
listening to others, taking
your turn to talk, finishing
homework without
interruptions, etc.
Positive consequences
of managing problems
differently; taking
responsibility for self-
12 Make a list of solutions that
help you handle problems
differently at home or
school. Write down how
that makes you feel.
Desirability of putting
intentions and plans
for behaving differently
into action; its effects
on the children’s lives
312 Intervention in School and Clinic 48(5)
MTA Cooperative Group. (2004). National Institute of Mental
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The text focuses on the definition of substitute family care and its basic forms that are applied and used in the Czech Republic. The historical progression of substitute family care is also mentioned to demonstrate that this issue is a part of human society. An integral part of the text is the statistical information. Furthermore, the purpose of the text is to point out the need for experts and professionals who are engaged with this problem and are working with this targeted group. Last but not least is the need for reflection on those changes that had to be made because of the change in attitudes concerning substitute family care
em>Developmental creative writing and the related areas of expressive writing and therapeutic writing have only recently arisen as significant areas of study; however, although recent research has determined that writing is good for your health, just expressing oneself on the page isn’t enough to promote personal development. In this paper, I set out to answer the question – how is personal development achieved in the context of therapeutic writing? In order to answer this question, I consider many definitions of personal development and writing as outlined by experts in the associated fields of expressive writing, therapeutic writing and developmental creative writing, and I also review concepts of the self as I consider a related question – who am I? Through an in-depth analysis of my own personal writing about my sister’s mental illness, I conclude that writing for the purposes of personal development requires a conscious self-reflexive effort, with the goal of developing a deeper understanding of self, so as to promote positive change in the way that one perceives one’s own life. </em
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Objective. In the Multimodal Treatment Study of ADHD (MTA), the effects of medication management (MedMgt) and behavior modification therapy (Beh) and their combination ( Comb) and usual community comparison ( CC) in the treatment of attention-deficit/ hyperactivity disorder ( ADHD) differed at the 14-month assessment as a result of superiority of the MTA MedMgt strategy ( Comb or MedMgt) over Beh and CC and modest additional benefits of Comb over MedMgt alone. Here we evaluate the persistence of these beneficial effects 10 months beyond the 14 months of intensive intervention. Methods. Of 579 children who entered the study, 540 (93%) participated in the first follow-up 10 months after the end of treatment. Mixed-effects regression models explored possible persisting effects of the MTA medication strategy, the incremental benefits of Comb over MedMgt alone, and the possible superiority of Beh over CC on 5 effectiveness and 4 service use domains. Results. The MTA medication strategy showed persisting significant superiority over Beh and CC for ADHD and oppositional-defiant symptoms at 24 months, although not as great as at 14 months. Significant additional benefits of Comb over MedMgt and of Beh over CC were not found. The groups differed significantly in mean dose ( methylphenidate equivalents 30.4, 37.5, 25.7, and 24.0 mg/day, respectively). Continuing medication use partly mediated the persisting superiority of Comb and MedMgt. Conclusion. The benefits of intensive MedMgt for ADHD extend 10 months beyond the intensive treatment phase only in symptom domains and diminish over time.
This book presents a respectful, often playful approach to serious problems, with groundbreaking theory as a backdrop. The authors start with the assumption that people experience problems when the stories of their lives, as they or others have invented them, do not sufficiently represent their lived experience. In this way narrative comes to play a central role in therapy.
This study explored the effectiveness of group narrative therapy for improving the school behavior of a small sample of girls with attention-deficit/hyperactivity disorder (ADHD). Fourteen clinics referred 9- to 11-year-old girls with a clinical diagnosis of ADHD were randomly assigned to treatment and wait-list control groups. Posttreatment ratings by teachers showed that narrative therapy had a significant effect on reducing ADHD symptoms 1 week after completion of treatment and sustained after 30 days.
101 More Favorite Play Therapy Techniques offers new techniques by therapists from all over the world. Separated into seven categories for easy reference, the techniques within each chapter are applied to practice situations in a concise format for easy reference and use. The interventions illustrated include Storytelling, to enhance verbalization in children; Expressive Art, to promote children's coping ability by using various art mediums; Game Play, to help children express themselves in a playful environment; Puppet Play, to facilitate the expression of conflicting emotions; Play Toys and Objects, to demonstrate the therapeutic use of various toys and objects in the playroom; Group Play, to offer methods and play techniques for use in group settings; and Other, to provide miscellaneous techniques that are useful in many settings. This book is a response to the evident need of clinicians for easy-to-use play therapy techniques. This manual is designed to help children enhance verbalization of feeling, manage anger, deal with loss and grief, and heal their wounds through play therapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Bruner (1986) and Sarbin (1986) have argued that people make sense of living by actively constructing stories containing characters moving toward goals through time. Both content and structure in these narratives are understood as promoting either flexible, adaptive functioning or psychological distress. Theories of psychotherapy can also be seen as stories about human function and dysfunction that incorporate many of the same ideas about reality, human nature and change that are found in clients' personal narratives. This narrative perspective, then, suggests that the therapeutic alliance might be improved and an integrative use of different theories might be made by selecting therapeutic approaches and interventions based on the degree of similarity between the nature of the client's life story and the story of human functioning incorporated in the theory. A classification of theories, examples of classification of client stories and some issues of implementation of this integrative proposal are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)