Narrative Intervention for Children With Autism Spectrum ... · Narrative Intervention for Children With Autism Spectrum Disorder (ASD) Sandra Laing Gillam,a Daphne Hartzheim,a Breanna

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Narrative Intervention for Children WithAutism Spectrum Disorder (ASD)
Sandra Laing Gillam,a Daphne Hartzheim,a Breanna Studenka,a
Vicki Simonsmeier,a and Ronald Gillama

Purpose: This study was conducted to determine whethera narrative intervention program that targeted the use ofmental state and causal language resulted in positive gainsin narrative production for children with autism spectrumdisorder (ASD).Method: Five children (2 girls and 3 boys) who had beendiagnosed with ASD participated in the study. Childrenranged in age from 8 to 12 years and were recruited throughan autism clinic. Intervention was provided for two 50-minindividual sessions per week for a total of 21–33 sessions(depending on the student). Children’s spontaneous stories,collected weekly, were analyzed for overall story complexity,

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ce to Sandra L. Gillam: [email protected]

Paultor: Linda Watson

ber 21, 2014ived February 2, 2015rch 27, 2015/2015_JSLHR-L-14-0295

al of Speech, Language, and Hearing Research • Vol. 58 • 920–933 • Ju

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story structure, and the use of mental state and causallanguage. Following a multiple-baseline across-participantsdesign, data were collected for lagged baseline andintervention phases over a 6-month period.Results: All of the children made gains on all 3 measuresof narration after participating in the instruction, with clearchanges in level for all 5 children and changes in trendfor 4 of the 5 children. The gains were maintained afterintervention was discontinued.Conclusion: The results demonstrate the efficacy of the3-phase narrative instruction program for improving thefictional narration abilities of children with ASD.

Children encounter narratives in virtually everyfacet of their lives, so it is not surprising that mostfirst graders are proficient at understanding and

creating stories (Skarakis-Doyle & Dempsey, 2008). Narrativediscourse is a means for communicating perceptions, feel-ings, values, and attitudes within cultural contexts (Nelson,1996). The ability to produce coherent and cohesive narra-tives has been linked to competence in socialization(McCabe & Marshall, 2006), working memory (Duinmeijer,de Jong, & Scheper, 2012), and academics (Wellman et al.,2011).

Children diagnosed with autism spectrum disorder(ASD) often experience difficulty comprehending and pro-ducing narratives, and these difficulties extend well intotheir adolescent and adult years (Eigsti, de Marchena,Schuh, & Kelley, 2011). Their narrative difficulties appearto be linked directly to core symptoms of ASD such as fail-ure to plan, difficulty using and integrating informationfrom multiple sources, a hyper-focus on details at the ex-pense of gist-level propositions, and limited use of mental

state and causal language to encode goals and motivationsof characters (Capps, Losh, & Thurber, 2000).

Executive functioning (EF), theory of mind (ToM),and weak central coherence theories have become promi-nent accounts of the core social and communication deficitsexperienced by children with ASD. Each of these theoreti-cal perspectives predicts deficits in narrative proficiency.According to the EF theory, children with ASD demon-strate deficits in one or more of the cognitive processes(e.g., working memory, inhibition, goal maintenance) thatunderlie the ability to plan appropriate responses and in-hibit inappropriate responses. Consistent with EF theory,narratives of children with ASD are often disorganized, in-clude limited causal relationships, and/or reflect poor un-derstanding of the main ideas (King, Dockrell, & Stuart,2013). According to ToM, a core deficit in ASD is an in-ability to infer the emotional or mental states of others.Deficits in ToM have been shown to significantly impairone’s ability to engage in ongoing social interactions and todevelop the linguistic knowledge (e.g., mental state andcausal language) necessary for understanding the relation-ship between events in discourse (Eigsti et al., 2011). Finally,weak central coherence theory links the social-communicativeproblems experienced by children with ASD to a preferencefor attending to specific details at the expense of integratinginformation into holistic mental representations. This could

Disclosure: Sandra Laing Gillam and Ronald Gillam have a financial interest in theintervention used in this study.

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lead to difficulties organizing information into coherentstories (Loukusa & Moilanen, 2009). To date, no single the-ory sufficiently accounts for all of the symptoms underlyingdifficulties in narrative by children with ASD. However,each of the three principle theories of ASD predicts difficul-ties in the ability to understand and produce coherent andcohesive narratives.

Narrative Proficiency of Children With ASDStories produced by children with ASD may be simi-

lar in length and complexity to those told by their typicallydeveloping peers. However, there are often notable differ-ences in story organization and in the establishment ofcausal coherence for conveying events in meaningful chains(Diehl, Bennetto, & Young, 2006). These differences mayresult from a failure to appreciate narrative structure as atool for organizing experiences in cohesive and coherentways (Solomon, 2004). Studies that have compared storiestold by children with ASD with those produced by age-matched and verbal mental-age-matched children withDown syndrome illustrate deficits in story organization andcausal coherence. In these studies, children with ASD weresignificantly less likely than children with Down syndrometo recognize and acknowledge central themes or motiva-tions and goals of characters. As a result, their stories wereless causally coherent and organized than stories told bychildren with Down syndrome (Grazzani & Ornaghi, 2012;King et al., 2013; Stringfield, Luscre, & Gast, 2011). Evenwhen children with ASD include internal state verbs andadverbs in their stories, they are more likely to use descrip-tive fragments (e.g., “He is sad. His dog ran away.”) andless likely to represent the thoughts and feelings of char-acters within a causal framework (e.g., “The boy was sadbecause his dog ran away”; Rollins, 2014).

The Importance of Story Structure andCausal Frameworks

Stein and Glenn (1979) proposed that stories arecharacterized by macrostructure and microstructure ele-ments. The macrostructure of a story consists of settingsplus episodes, which contain propositions such as initiatingevent (problem/event), internal response (feelings aboutthe initiating event), attempt (goal-directed actions relatedto the initiating event), consequence (consequence of theactions), and reaction (feelings about the consequence).Stories also contain a microstructure, which consists of thewords and sentences that combine to form the macrostruc-ture. Aspects of the microstructure such as causal con-junctions can signal the storyteller’s understanding of causalrelationships within the story. Research has shown thatchildren’s understanding and use of causal connectionsin narratives predicts reading comprehension (White,van den Broek, & Kebndeou, 2007) and influences writing(van den Broek, Linzie, Fletcher, & Marsolek, 2000) andanalogic thinking (McGill, 2002) as well as causal reasoningand decision making (Perales, Catena, & Maldonado, 2004).

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Narrative Intervention for Children With ASDWe located two reports of the outcomes of narrative

intervention with school-age children with ASD. Petersenet al. (2014) studied the outcomes of a narrative interven-tion that focused on improving personal narratives for chil-dren with ASD. Using a single-subject, multiple-baselineacross-behaviors design, these authors targeted two to threestory grammar elements and two to three syntactic struc-tures that had been identified as deficient in each child’sbaseline stories. Narrative instruction was provided for upto 12 sessions by three graduate-level clinicians participat-ing in clinical training at a university clinic. The cliniciansused customized stories that modeled the story elementsand linguistic forms that had been targeted for each child.Instruction involved picture icons and story drafting withthe aid of “sticky notes.” Linguistic instruction was pro-vided through verbal modeling and prompting during thesessions. The clinicians followed a loosely scripted series ofeight steps involving modeling, retelling, and generatingstories that was similar in nature to the intervention de-scribed by R. B. Gillam and Ukrainetz (2006), Petersen,Gillam, Spencer, and Gillam (2010), and S. L. Gillam andGillam (2014). In each step the visual and verbal supportthat was provided to the participants was reduced.

One of the three children made large gains in his useof the specific story grammar elements (e.g., action, problem,emotion, end emotion, plan, location) that were targeted andin his use of various linguistic forms (e.g., temporal con-junctions, causal adverbial subordination, temporal adver-bial subordination, adverbs, adjectival subordination). Theother two children made moderate gains during interventionfor some target structures and minimal gains for others.None of the children maintained their improvements imme-diately after treatment ended.

Dodd, Ocampo, and Kennedy (2011) studied the out-comes of a narrative intervention for improving knowledgeof mental state and causal language for school-age childrenwith ASD. They recruited 18 children with ASD between theages of 9 and 12 years to participate in one of two narrativeinterventions: perspective taking instruction or narrative-based language instruction (NBLI). Perspective taking in-struction focused on knowledge of character emotion andcognitive states and on perspective taking. NBLI targetedsequencing, organization, use of transitional wording, andvocabulary not related to emotion and cognitive states(Dodd et al., 2011). Over the course of 6 weeks, childrenreceived instruction in groups of five for 30-min sessions threetimes per week. The Story Grammar Marker (Moreau &Fidrych-Puzzo, 1994), which is a visual manipulative repre-senting story grammar elements, was combined with storymapping strategies to teach story grammar elements andperspective taking for children in the perspective taking in-struction group. Advanced story mapping procedures wereused to teach concepts to children in the NBLI group.Change in narrative skill was measured by asking childrento retell a story from the perspectives of various characters.In addition, retells were evaluated for the number and

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Table 1. Mean scores on the Clinical Evaluation of LanguageFundamentals–Fourth Edition (CELF-4) and the Universal NonverbalIntelligence Test (UNIT) for all participants prior to participation inthe intervention program.

Participant Age (years;months) CELF-4 UNIT

Set 1Rosa 10;8 85 85Jack 8;4 79 103Violet 9;5 114 115

Set 2Bob 10;9 62 78Gary 9;6 48 91

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diversity of psychological terms that were used. The authorsreported a large effect size (d = .96) for pre- to posttest dif-ferences in retells for children in the perspective taking con-dition and a moderate effect size (d = .41) for those in theNBLI condition. The authors interpreted these findings asevidence that children who received instruction in perspec-tive taking and vocabulary related to character emotionand cognitive states demonstrated greater growth in theseskills than children who did not receive this instruction.However, there was no global measure of narrative profi-ciency outside of the outcome measures used to assessproduction of mental terms and perspective taking skill.Therefore, we cannot determine with any certainty thateither instructional approach resulted in children telling bet-ter stories.

This article reports the findings of a multiple-baselineacross-participants study conducted to assess the efficacyof a three-phase narrative intervention program. We askedwhether narrative instruction designed to increase theability to produce stories containing complete episodes aswell as mental state verbs and adverbs (e.g., think, know)and causal conjunctions (e.g., because, so) resulted in im-provements in the narratives produced by children withASD. We used a multiple-baseline across-participants de-sign with two sets of children (three who were higher func-tioning and two who were lower functioning). Interventionbegan for the first participant in each set after three baselinesessions. The beginning of subsequent intervention phasesfor the additional participants was lagged by three sessions.Follow-up testing was conducted to determine whetherthe intervention effects were maintained after interventionwas discontinued. No measure of generalization to otherskills (e.g., social, educational) was administered.

MethodParticipants

Five children (two girls and three boys) between 8and 12 years of age were recruited through an autism clinic.All the participants were monolingual English speakerswith an educational diagnosis of autism. The children hadstandard scores of 70 or above on the screening portion ofthe Universal Nonverbal Intelligence Test (UNIT; Bracken& McCallum, 1998). They were characterized as verballyfluent on the Autism Diagnostic Observation Schedule(ADOS-2; Lord et al., 2012). Four of the children earnedstandard scores at or below 85 on the Clinical Evaluationof Language Fundamentals–Fourth Edition (CELF-4;Semel, Wiig, & Secord, 2003). One child’s CELF-4 scoreswere above average (114), but her stories lacked coherenceor cohesiveness (see Table 1 for mean scores on the UNITand the CELF-4).

We collected spontaneous stories about picture promptsbefore intervention. Three children (Rosa, Violet, and Jack)produced stories that contained basic story elements (initi-ating event, attempts, consequences) but did not contain in-ternal responses or plans. Their stories, although sometimes

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long and detailed, had ambiguous story organization anddeficiencies in the establishment of causal and temporal co-herence. Whereas Rosa and Violet sometimes made refer-ence to characters and settings by name, Jack never did so.In terms of microstructure, neither Rosa nor Violet usedsubordinated clauses containing causal language, and theyrarely used mental (e.g., thought) and linguistic (e.g., said,yelled ) verbs. Jack used coordinated and subordinatedclauses, adverbs, and elaborated noun phrases inconsis-tently but never used causal terms (e.g., because) to connectelements in his stories. Two other participants, Bob andGary, did not tell stories with basic episodes. When askedto create stories about single scenes that depicted possibleinitiating events, Bob and Gary provided simple descrip-tions of objects or actions (e.g., “There’s a boy,” “They areon the beach”). They were not observed to use coordinatedclauses, subordinated clauses, adverbs, mental or linguisticterms, or elaborated noun phrases in their descriptions.

Outcome MeasuresWe elicited spontaneous narratives during each base-

line session, after every other instructional session, and dur-ing two follow-up sessions by asking children to create astory that corresponded to a single-scene prompt. Five dif-ferent examiners collected the stories after showing the par-ticipants photos that contained obvious initiating eventssuch as children losing pets or money, missing buses, or get-ting injured. The examiners said, “I am going to show youa picture. I want you to make up a story using this picture.Tell the best story you can. You can think about it for aminute. Start when you are ready.” No prompting or mate-rials used during instructional sessions were used during thetesting session. Examiners did not prompt the students ex-cept to ask whether their story was completed. Stories wererecorded using a digital recorder and uploaded to a secureserver.

Research assistants who were blind to the purposeof the research transcribed the stories told by children ac-cording to Systematic Analysis of Language Transcriptsconventions (Miller & Chapman, 2004). The spontaneousnarratives were transcribed verbatim with the inclusion ofboth child and examiner utterances when applicable. Thestories were segmented into communication units (Loban,

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1976) that consisted of an independent main clause and anyphrases or clause(s) subordinated to it. Each transcript waschecked by a second research assistant for word spelling,mazing, morpheme segmentation, and utterance segmenta-tion. All transcription disagreements were resolved as thetwo transcribers listened to the digital recording togetherfor a third time.

The Monitoring Indicators of Scholarly Language(MISL) rubric was used to measure narrative proficiency,knowledge of story elements, and perspective taking inspontaneous stories told by children (S. Gillam & Gillam,2013). There are seven items on the MISL used to measuremacrostructure and six items to measure microstructure.For macrostructure, each item (character, setting, initiatingevent, internal response, plan, attempt, and consequence)was weighted to a score of 2 and reflected whether an ele-ment was absent (score of 0), emerging (score of 1), present(score of 2), or elaborated (score of 3). The total possiblescore for macrostructure was 21. For an elaborated discus-sion of the scoring guidelines for the MISL, see the onlinesupplemental materials.

For each of the six items that measured microstruc-ture, a score of 0 was assigned if no exemplars were present,a score of 1 was assigned if the story contained one exampleof the structure, a score of 2 was assigned if two differentexemplars were present, and a score of 3 was assigned ifthere were three or more different exemplars of the struc-ture within the story. The MISL microstructure items forthis project included coordinating conjunctions, subordinat-ing conjunctions, adverbs, mental verbs, linguistic verbs,and elaborated noun phrases. The scores on each scaleranged from 0 to 3. The total possible score for microstruc-ture was 18.

The total combined macrostructure and microstruc-ture score on the MISL was used as an index of overall nar-rative complexity. In addition, we created two subscalesof items specifically for this study. The Story KnowledgeIndex was calculated by combining the critical elementsof a story (initiating event + internal response + plan +attempt + consequence). The Perspective Taking Index wascalculated by adding scores earned for internal response,plan, and mental/linguistic verbs.

As a check on the accuracy of the original transcrip-tion and coding process, 20% of the transcripts were retran-scribed. Percentage of agreement between primary andsecondary transcribers was 96% for communication-unitsegmentation and 96% for the identification of mazes. Thefirst and second authors, who were not blind to the purposeof the study, independently scored 20% of the deidentifiedtranscripts of the narratives using the MISL rubric. Inter-rater reliability for the MISL total score was 95%. Theinterrater reliability scores for the story knowledge and per-spective taking indexes were 96% and 97%, respectively.

Narrative InterventionThe intervention used in this study is manualized and

was implemented in a university clinic. Parents observed


sessions but did not participate in them. The narrative inter-vention contained three phases—Phase 1: Teaching StoryElements, Phase 2: Connecting and Elaborating Stories,and Phase 3: Creating and Editing Stories. During Phase 1,participants were taught core story elements (character, set-ting, initiating event, internal response, plan, attempt, con-sequence, and reaction). Each element was depicted with anicon (e.g., smiley face for internal response; rocket takingoff for initiating event) and included on a storyboard. Eachstory element was explained and illustrated using wordlesspicture books designed specifically for the intervention pro-gram. These books were loaded onto iPads. As the cliniciantold the story shown on the iPad, each story element wasverbally defined and examples were provided. After allthe elements were addressed, the children participated inlessons during which they were asked to identify each ele-ment in the model stories and to use them in creating newstories. The new stories (e.g., parallel stories) were similarto the modeled stories but differed in one or two elements(e.g., different characters, a different action). Parallel storieswere drafted onto a storyboard containing the story iconsby drawing stick pictures (Ukrainetz, 1998). Once the par-ticipants were successful in creating and retelling their ownstories with the icons and storyboards, they practiced tellingthem without the support.

At the end of each phase we conducted contextual-ized, literature-based activities using children’s trade books(see S. L. Gillam, Gillam, & Reece, 2012). References forall of the literature books used in the instruction may befound in the online supplemental materials. Each literatureunit began with a prestory presentation to show childrenthe book and title and was followed by a word review. Afterthe vocabulary review, the book was read to the child.As the story was read, the clinician highlighted the storyelements verbally and by using the icons and graphic orga-nizers. Children were asked to answer questions related tothe story elements and to retell the story with and withouticons, picture manipulatives, and storyboards. During eachphase, children engaged in minilessons targeting knowledgeand use of concepts that contribute to narrative proficiency.For example, in Phase 1, children were engaged in lessonsteaching the concepts of before and after, first within thecontext of the literature book and then in independent prac-tice activities involving real-life situations (e.g., you mustcook the brownies before you eat them).

After each participant completed the 18 lessons inPhase 1, exit testing was conducted to determine whetherchildren were prepared to move on to Phase 2. In order tobegin Phase 2, children had to (a) identify by name all ofthe icons, (b) give satisfactory examples and/or definitionsfor each icon, (c) be able to create a story about a picturethat contained all of the elements (with assistance), and(d) answer comprehension questions related to the story ele-ments. In the event that one or more of these criteria werenot met, specific instructions and additional materials wereprovided in the manual relative to each skill and were usedto reteach them. This process continued until the exit-testingcriteria were met.


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Phase 2 (Connecting and Elaborating Stories) was de-signed to teach linguistic structures, concepts, and vocabu-lary for use in creating more elaborate, complex stories.Instruction in Phase 2 highlighted the importance of mak-ing connections between story grammar elements and usingmental state and causal language, and it included instructiondesigned to broaden knowledge of microstructure (e.g., useof coordinating and subordinating conjunctions, adverbs,elaborated noun phrases, and mental state and causal lan-guage). Children were introduced to the use of dialogue asa way to elaborate their stories (e.g., said, yelled, told ) andparticipated in activities focused on the inclusion of compli-cating events as a means to produce more complex stories.During all lessons, emphasis was placed on establishing andmaintaining connections between the story elements byusing mental state and causal language. For example, chil-dren were encouraged to create stories that contained wordssuch as because and so to explain why a character felt a cer-tain way or why he or she planned to take various actions.

At the end of Phase 2, children participated in con-textualized, literature-based activities that were based on adifferent, slightly more complex children’s trade book thatcontained multiple examples of elaborated noun phrases.The lessons were similar to that of Phase 1; however, addi-tional icons (e.g., dialogue, plan again) and a more elabo-rate story board that incorporated plan-again icons wereadded to provide support for the creation of more elabo-rated stories. Activities were conducted within the contextof the literature book and then in independent practiceactivities involving the use of vertical structuring. For ex-ample, children were given a scenario (“The boy fell off hischair”) and asked to tell how the character in the scenariofelt (Child: “embarrassed”). Then, children were asked toexplain why the character may have felt that way (Child:“because he fell off his chair”). The two responses werecombined by the clinician and modeled back to the child(Clinician: “The boy was embarrassed because he fell offhis chair.”). This procedure provided the child with a modelof the use of causal state language in a complex sentence.

Exit testing was conducted to determine whether chil-dren were prepared to move on to Phase 3 (Creating andEditing Stories). In order to begin Phase 3, children wererequired to create a story about a picture that included allof the story elements, the words because or so, and two ormore feeling words plus one or more mental or linguisticverbs, one or more adverbs, and one or more elaboratednoun phrases. They also had to answer comprehensionquestions and recall story details. Additional instructionsand materials were used to reteach any of the skills childrendemonstrated continued difficulty with until they met theexit-testing criteria.

Phase 3 was designed to give children multiple op-portunities to create, tell, edit, and revise their own spon-taneously generated stories with and without icon andstoryboard support. All of the lessons were conductedwithin the context of literature books that contained multi-ple, embedded episodes and more complex concepts, vocab-ulary, and syntax than Phases 1 and 2. Phase 3 began with



literature-based activities and was followed by guided andindependent practice activities on the use of cause-and-effectrelationships signaled by conditional clauses containingthe adverbs if and then. The structure was taught using thecontent of the book (e.g., if the whale gets stuck, then heshould ask others for help pushing him off the sand) andthen extended to real-life situations (e.g., if you found apuppy, then you should try to find the owner). Cliniciansused additional books to teach this concept when childrendid not appear to be demonstrating sufficient understanding.

The major focus of Phase 3 was to provide childrenwith opportunities to develop independence in their under-standing and use of narrative macrostructure and micro-structure. In addition, lessons were designed to fostermetacognitive skills necessary for children to judge the ade-quacy of their own stories. Toward this end, children weretaught to use a self-scoring rubric to edit their stories. Therubric contained questions targeting macrostructure andmicrostructure elements in stories. For example, the rubricasked, “Does the story have at least 2 characters?” and “Doesmy story have words that relate to thinking or dialogue?”Children used the self-scoring rubric first with the book LittleCroc and Whale (Maddox, 2009) and then in stories createdfrom sequenced scenes and single-scene prompts.

Treatment FidelityAn observation checklist was designed to accompany

each lesson taught in the intervention program. The inter-vention observation checklist was used by a member of theresearch team who observed the session to track that allaspects of the lesson were being taught. If fidelity fell below85% for any lesson, the research staff held a short meetingwith the interventionist immediately after the lesson to talkabout what was omitted. There were sessions during whichthe intervention failed to meet the minimum fidelity require-ment; however, it was usually due to the fact that therewas insufficient time to complete the lesson. The omitted in-formation was always introduced in the following sessionafter a brief review of the previous session. A member ofthe research team who did not observe the lesson in personrated 20% of the lessons via videotape. Interrater reliabilityfor implementation of lessons was calculated point bypoint and was 95% or greater for all of the lessons that wereviewed.

DesignWe used a concurrent multiple-baseline across-

participants design. The five participants were divided intotwo sets. The first set of participants with higher languageability included Rosa, Violet, and Jack. The second set ofparticipants with lower language ability included Bob andGary. Within each set, participants began baseline at thesame general point in time to control for external influ-ences on participant performance (Carr, 2005). The onsetof intervention was lagged for the other participants ineach set to control for maturation and history threats to

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internal validity. The first child in each set (Rosa and Bob)started intervention at the same time.

Data AnalysisFollowing Kratochwill et al. (2010), we used the fol-

lowing steps for conducting visual analysis of the data fromthis project. First, we observed whether there was a pre-dictable pattern in the data during the baseline phase. Next,data obtained within the baseline and intervention phaseswere evaluated for the presence of predictable patterns.After within-phase inspection, we examined whether therewas evidence that the intervention phase was associatedwith the expected change in total MISL scores. Featuresthat were used to examine within-phase and between-phases(baseline and intervention) data patterns included (a) level(mean scores for data within a phase), (b) trend (slope ofbest-fitting straight line for data within phase), (c) variabil-ity (range of data about the best-fitting straight line), (d) im-mediacy of effect (change in level between last three datapoints in baseline and first three data points in interven-tion), (e) overlap (proportion of data from one phase thatdo not overlap with data from previous phase), and (f) con-sistency of data patterns across phases (extent to whichthere is consistency in the data patterns in baseline and in-tervention; Kratochwill et al., 2010).

There is debate in the literature about the use of vi-sual analysis and statistical procedures for interpreting out-comes in single-subject studies (Scruggs & Mastropieri,2001). Proponents of the use of visual analysis have pointedout that single-case studies do not meet the assumptionsupon which many statistical methods depend. This is partic-ularly relevant for studies with children from low-incidencepopulations such as ASD who may not meet the assump-tion for homogeneity of variance. Furthermore, under someconditions, alternate statistical analyses may mask patternsin the data that a visual analysis would ascertain. However,the American Psychological Association (APA Publicationsand Communications Board Working Group on JournalArticle Reporting Standards, 2008) recommends that allstudies submitted for publication include measures tomake it easier to interpret findings across studies. Follow-ing recommendations by Olive and Smith (2005), we calcu-lated percent of nonoverlapping data (PND) across thebaseline and treatment phases (number of data points dur-ing the treatment phase that did not overlap with the high-est baseline point / the total number of data points in thetreatment phase) and percent of improvement over baseline(PIB), which is (the quotient of the average of the last threeintervention data points − the baseline average) / the base-line average × 100. We also combined the use of standardmean difference (SMDall) with procedures for conductingvisual analysis for evaluating the magnitude and strength ofintervention effects in this project. SMDall was calculatedfrom the mean performance data during baseline and inter-vention divided by the standard deviation of the baselinemean. The data for SMDall are presented as online sup-plemental materials. In addition to SMD calculations, the


supplemental materials include a qualitative summary ofeach child’s response to the instruction. This information isincluded to provide clinicians with a more complete under-standing of the nature of the changes that were made byeach of the participants.

Data InterpretationThe baseline and intervention scores for the MISL

total, the MISL Story Knowledge Index, and the MISLPerspective Taking Index are illustrated in Figures 1, 2, 3,and 4. PND and PIB for each participant for the total andeach index are shown in Tables 2, 3, and 4, respectively.Recall that the self-generated stories on which these datapoints were based were collected once weekly.

Participant Set 1 (Rosa, Jack, and Violet)Rosa

Baseline. Visual data for Rosa’s MISL, Story Knowl-edge Index, and Perspective Taking Index scores are pre-sented in Figures 1 and 2. Rosa attended five baselinesessions prior to beginning intervention. There was a de-creasing trend in all three narrative indexes during the lastthree baseline sessions. Rosa earned high scores (2 or higher)during baseline on the MISL for use of character (gavecharacters’ names), but other macrostructure items (e.g.,setting, initiating event, action, consequence) varied widely,with her highest scores earned during Baseline Session 2(a story about a scene depicting a crowd of people at thebeach). At no time did Rosa score a 2 or higher on internalresponse or plan during baseline, nor did she earn a scoregreater than 1 for use of mental verbs. Rosa used linguisticverbs during Baseline Session 1; however, only one of thesubsequent four baseline stories contained a linguistic verb(i.e., said ).

Intervention. Rosa attended 23 intervention sessionsspread across 11 weeks. She spent nine sessions in Phase 1,eight in Phase 2, and six in Phase 3, and she participatedin two follow-up sessions. MISL scores were obtained onceweekly (after every other intervention session) for a total of12 data points. Figures 1 and 2 show clear trend and levelfrom baseline to intervention for all three narrative indexes.The effects were not stable until the third phase of the inter-vention program. MISL scores for eight of the 12 storiesthat were produced during the intervention phase were abovethe highest scores obtained during baseline (MISL = 22),resulting in a PND of 67%.

Rosa’s Story Knowledge Index scores increased tothe criterion of 10 or above within the first 2 weeks of inter-vention and were maintained for all but three of the 12 datapoints during intervention. The PND for the Story Knowl-edge Index was 75%, and there was a large PIB (256%).Rosa’s narratives reflected greater knowledge of criticalstory elements (initiating event, action, and consequencescores of 2 or higher) for all of the sessions during interven-tion with the exception of Session 9. Rosa’s PerspectiveTaking Index increased to criterion within 2 weeks after


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Figure 1. Results of Monitoring Indicators of Scholarly Language (MISL) scores for Rosa, Jack, and Violet.

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beginning intervention and was maintained for all buttwo of the eight data points. The PND for her PerspectiveTaking Index score was 67%, with an 86% improvementover baseline.

Maintenance. Rosa completed two maintenance ses-sions. For all three measures (MISL, Story KnowledgeIndex, and Perspective Taking Index), her scores remainedwell above her highest baseline scores. In addition, Rosa’sStory Knowledge Index and Perspective Taking Index scoresremained at or above criterion, demonstrating appropriate



knowledge of story structure, mental state, and causal lan-guage for both time points (Story Knowledge Index ≥ 10;Perspective Taking Index ≥ 6).

JackBaseline. Jack remained in baseline for nine sessions

prior to beginning intervention. His MISL scores werehighly variable and followed an upward trend during base-line. Jack’s parents were anxious for him to begin treat-ment, so we decided to go ahead and initiate treatment

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Figure 2. Results of Perspective Taking Index (PTI) and Story Knowledge Index (SKI) for Rosa, Jack, and Violet.

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even though his baseline data were trending upward. Jackdemonstrated knowledge of the crucial elements of stories(initiating event, action, and consequence scores of 2 orhigher) in six of the nine baseline sessions. Jack included aninternal response in one story during baseline but did notinclude plans, mental verbs, or linguistic verbs. At no timeduring baseline did Jack meet the minimum criteria for per-spective taking (Perspective Taking Index ≥ 6).

Intervention. Jack participated in 21 intervention ses-sions across 11 weeks. He spent 11 sessions in Phase 1,


six in Phase 2, and five in Phase 3, and he participated intwo follow-up sessions. His scores on the MISL, the StoryKnowledge Index, and the Perspective Taking Indextrended upward at a rate that was consistent with the base-line trend. Therefore, Jack’s results do not rule out historyor maturation threats to internal validity. Similar to Rosa,there were consistent changes in level of performance acrossall three measures. Jack’s MISL scores for eight of 11 ofhis stories were at or above his highest baseline score of 24.The PND for the MISL was 73%, and he evidenced 116%


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Figure 3. Results of Monitoring Indicators of Scholarly Language (MISL) scores for Bob and Gary.

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improvement over baseline. Jack’s Story Knowledge Indexscores increased to criterion (scores greater than 10) by theend of Phase 1 of intervention, and he maintained this levelfor all but three data points. For the Story Knowledge In-dex, the PND was 73%, and there was a 234% improvementover baseline. After intervention began, Jack maintainedthe criterion score of 6 or above on the Perspective TakingIndex, and he maintained that level for all but one of the11 data points. For perspective taking, the PND was 73%,and there was 527% improvement over baseline.

Maintenance. Jack participated in two maintenancesessions. His MISL, Story Knowledge Index, and Perspec-tive Taking Index scores were stable with his performanceduring Phase 3 of intervention and were well above hishighest baseline scores. In addition, Jack’s Story Knowl-edge Index and Perspective Taking Index scores remainedat or above criterion for demonstrating knowledge of storystructure, mental state, and causal language.

VioletBaseline. Violet attended 12 baseline sessions prior to

beginning intervention. There were downward trends in herMISL, story knowledge, and perspective taking scores dur-ing baseline, which controlled for history and maturationeffects for Rosa. She earned a score of 2 or higher for



internal response in one story she told during baseline.She earned scores of 1 or 2 for use of mental verbs duringfive of 12 baseline sessions and a score equal to or greaterthan 1 for linguistic verbs in 10 of 12 baseline sessions. Atno time during baseline did Violet meet the minimum cri-teria for the Perspective Taking Index (≥6).

Intervention. Violet participated in 19 interventionsessions over 10 weeks. She spent eight sessions in Phase 1,six in Phase 2, and five in Phase 3, and she participated intwo follow-up sessions. There were clear changes in trendand level after intervention was initiated, which supportsthe causal relationship between the intervention and theoutcomes for both Violet and Rosa. There were six of10 data points during intervention when the PND for theMISL was 60% and PIB was 46%. Violet’s story knowledgescores increased to criterion within the first 2 sessions (≥10),and she maintained this level for five of the 10 data points.The PND for the Story Knowledge Index was 50%. PIBwas 148%. After beginning intervention, Violet’s Perspec-tive Taking Index score increased to criterion (≥6) and wasmaintained for all but three of the 10 data points. PND forthe Perspective Taking Index was 58%, and there was a202% improvement over baseline.

Maintenance. For the first maintenance session, Violet’sMISL, story knowledge, and perspective taking scores were

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Figure 4. Results of Perspective Taking Index (PTI) and Story Knowledge Index (SKI) for Bob and Gary.

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consistent with her performance during the last two inter-vention sessions. Performance on all three measures droppedduring the second baseline sessions, but the scores on allthree measures remained above the highest baseline scores.

Participant Set 2 (Bob and Gary)Bob

Baseline. Visual data for Bob’s MISL, Story KnowledgeIndex, and Perspective Taking Index Scores are presentedin Figures 3 and 4. Bob attended four baseline sessionsprior to beginning intervention. There were downwardtrends in MISL, story knowledge, and perspective takingscores during baseline. Bob did not produce any storieswith basic episodes during baseline. He was not observed tomeet criterion for story knowledge (a score of 10) or per-spective taking (a score of 6) during baseline.

Intervention. Bob participated in 33 intervention ses-sions across 17 weeks. He participated in 17 sessions duringPhase 1, nine in Phase 2, and seven in Phase 3, and heattended two follow-up sessions. There was a clear change


in trend and level after intervention began in all three in-dexes. There was high variability in Bob’s scores untilPhase 3 of the intervention. Bob’s MISL scores were abovehis highest baseline score during all but one of the inter-vention sessions. The PND for the MISL was 95%, andthere was 822% improvement over baseline. Bob’s storyknowledge scores increased to criterion at the beginning ofPhase 2 (after he had received approximately 9 weeks ofinstruction), and he maintained this level of story knowl-edge for all but two of the remaining seven data points. ThePND for the Story Knowledge Index was 57%, and therewas 464% improvement over baseline. Bob met criterionfor the Perspective Taking Index (a score of 6) just beforehe met criterion for the Story Knowledge Index. His PTIscores remained at criterion for four of the remainingeight sessions. The PND was 53%, and there was 280%improvement over baseline.

Maintenance. Bob participated in two maintenancesessions. His MISL scores and his story knowledge scoresremained above the baseline levels for both maintenancesessions. Bob’s perspective taking scores fell below the


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Table 2. Monitoring Indicators of Scholarly Language (MISL) totalscore, percent nonoverlapping data (PND), and percent improvementover baseline (PIB) for each participant.

Participant

Baseline TreatmentPND(%)

PIB(%)M (SD) M (SD)

Set 1Rosa 17.20 (4.44) 27.58 (6.40) 71 86Jack 13.67 (6.16) 26.64 (5.30) 77 116Violet 19.00 (3.46) 24.90 (5.51) 58 46

Set 2Bob 3.00 (1.41) 16.56 (9.16) 95 822Gary 2.00 (1.15) 9.69 (4.73) 81 433

Table 4. Perspective Taking Index (PTI) score, percent nonoverlappingdata (PND), and percent improvement over baseline (PIB) for eachparticipant.

Participant


PIB(%)M (SD) M (SD)


Set 2Bob 1.75 (1.26) 3.19 (2.69) 53 280Gary 0.30 (0.67) 0.92 (1.12) 19 123

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highest baseline level during the first maintenance sessionbut increased to the average of the scores obtained duringtreatment for the second baseline session.

GaryBaseline. Gary’s MISL, Story Knowledge Index, and

Perspective Taking Index scores are shown in Figures 3and 4. Gary attended 10 baseline sessions prior to begin-ning intervention. His baseline scores for all three indexeswere low and flat. Gary demonstrated limited knowledge ofthe crucial elements of stories in all baseline sessions. Hedid not meet our criterion for story knowledge or perspectivetaking during baseline.

Intervention. Gary participated in 27 intervention ses-sions across 14 weeks. He attended 17 sessions spent inPhase 1, three in Phase 2, and seven in Phase 3, and heparticipated in two follow-up sessions. There were clearchanges in level and slope for the MISL and Story Knowl-edge Index, with the clearest change occurring for storyknowledge. Performance on the Perspective Taking Indexvaried widely with a downward trend across Phases 2 and 3of the intervention. Gary’s MISL scores were above hishighest score obtained during baseline for 11 of the 14 ses-sions after which data were collected. The PND for theMISL was 81%, and there was a 433% improvement overbaseline. Gary’s story knowledge scores were above hishighest baseline score for all but one of the 13 interventiondata points. The PND for the Story Knowledge Index was

Table 3. Story Knowledge Index (SKI) score, percent nonoverlappingdata (PND), and percent improvement over baseline (PIB) for eachparticipant.

Participant


PIB(%)M (SD) M (SD)


Set 2Bob 2.50 (1.73) 6.76 (4.40) 57 464Gary 0.60 (0.52) 3.21 (1.81) 79 803



79%, and there was an 803% improvement over baseline.Gary included internal responses and plans in three of his13 stories. He included mental verbs in four stories and lin-guistic verbs in five of his stories. The PND for the Per-spective Taking Index was very small (19%), and there was a123% improvement over baseline.

Maintenance. Gary participated in two maintenancesessions. His MISL and story knowledge scores droppedduring the first maintenance session. However, scores on allthree measures increased to levels that were near the highestintervention score for the MISL and the Perspective Tak-ing Index. His score for the Story Knowledge Index duringthe second maintenance session was well above any of thescores he earned during intervention, however his perfor-mance remained variable. The variability in Gary’s perfor-mance that was observed during intervention continuedduring maintenance.

DiscussionOur research goal was to determine whether the intro-

duction of a three-phase approach to narrative interven-tion caused reliable changes in overall story complexity,knowledge of story structure and causality, and knowledgeof mental state and causal language in verbal childrenwith ASD. Our multiple-baseline study documented clearchanges in level of performance after the intervention wasinitiated (see Figures 1–4). There were clear changes in levelfor all five participants and changes in trend from base-line to intervention phases of the study for four of the fiveparticipants, suggesting that the intervention caused thechanges in the dependent measures while controlling for avariety of threats to internal validity related to history, mat-uration, subject selection, instrumentation, testing, or statis-tical regression. One participant, Jack, had a rising trendduring baseline. For that participant, it is possible thatoutside influences and/or maturation contributed to hischanges in narration. However, the data from the otherfour participants combine to make a good case for experi-mental control.

All of the children who participated in the studydemonstrated moderately large to extremely large gainsin overall narrative proficiency after intervention was

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implemented, as measured by the MISL total score. More-over, the children maintained many of their gains up tofour weeks after intervention ended. We did not assess thechildren’s use of language in other contexts (such as conver-sation), so we cannot comment on the extent to whichthis intervention is likely to generalize to other types ofdiscourse.

Recall that we reported three metrics of changes inlevel from baseline to intervention phases: SMDall, whichis discussed in the online supplemental materials, PND,and PIB. The PND scores ranged from 58% to 95%, andthe PIB ranged from 86% to 822%. Improvement in overallnarrative proficiency was most notable for the participantsin Set 2 (Bob and Gary), who demonstrated very low levelsof narrative skills before intervention. Bob and Gary earnedMISL scores during intervention that were four timeshigher than their baseline scores. The children in Set 1(Rosa, Violet, and Jack), who started the study with some-what higher narrative abilities, also made notable gains innarrative proficiency.

The Story Knowledge Index, which measured thecoherence among story elements by weighting scores forinitiating event, internal response, plan, action, and conse-quence, improved noticeably for both sets of participantsafter instruction. Across the five children, PND rangedfrom 50% to 79%, and PIB ranged from 145% to 803%. Thechildren in Set 1 (Rosa, Violet, and Jack) reached the mini-mum criterion for demonstrating basic story knowledge(a score of 10 or higher) during treatment and maintainedthat level of performance. The children in Set 2 (Bob andGary) made improvements in their story knowledge scoresduring treatment, but neither Bob nor Gary reached criterionon this measure.

Perspective taking, measured by combining scoresfor internal response, plan, and the use of mental andlinguistic verbs on the MISL, was shown to improve notice-ably for all five children in the study. The PND for perspec-tive taking ranged from 19% to 77%, and PIB ranged from86% to 527%. The children in Set 1 (Rosa, Violet, and Jack)met the criteria for basic knowledge and use of perspectivetaking, but the children in Set 2 (Bob and Gary) did not.We do not believe intensity of instruction was the majorfactor in explaining this finding because Bob and Gary re-ceived more instruction (≥27 sessions) than Rosa and Jack(19–23 sessions). The most likely explanations for this find-ing were that Bob and Gary had lower initial languageproficiency and more skills to learn over the course of thestudy than Rosa, Violet, and Jack. This relates to the issueof cognitive resource allocation and the potential to over-load children’s capacity during instruction. A number ofthe intervention sessions focused on language targets suchas the use of adverbs and elaborated noun phrases. It ispossible that these lessons might have overtaxed Bob andGary’s cognitive and linguistic abilities. For children withASD, lessons on adverbs and elaborated noun phrasesmight be more effective if they are provided after storyknowledge and perspective taking have been well estab-lished. This could prevent children’s cognitive and


linguistic resources from being overtaxed during interven-tion activities.

Clinical ImplicationsThe instruction that was provided in this study resulted

in positive outcomes for narrative comprehension and pro-duction for children with ASD. Specifically, children demon-strated overall gains in story complexity that reflectedimprovements in both story structure knowledge and themental state and causal language used in stories. Childrenwith ASD with lower language skills performed better onthe Story Knowledge Index than the Perspective TakingIndex, whereas the children with higher language skills per-formed well on both. Extended instruction may be requiredfor children with lower language abilities to fully master themental verbs and adverbs in stories.

The children with ASD who participated in this studymade remarkable gains in their narrative skills over a rela-tively short period of time. One potential reason for theirsuccess may be related to the way the causal coherence,macrostructure, and microstructure elements were taught.The narrative curriculum used in this study provided chil-dren with maximum external support for learning and forretrieval of information used in comprehending and com-posing fictional narratives. For example, in early lessons,children are provided a great deal of scaffolding using exter-nal visual cues (e.g., icons representing the story elements)and graphic organizers that provide a visual means for orga-nizing each of the icons for representing stories. Over time,the organizational scaffolds are reduced adaptively, accord-ing to the level of mastery students demonstrate on thecomprehension and composition tasks. This approach mayplay a critical role in ensuring the success of narrative in-struction for children with ASD, who frequently demonstrateweak verbal memory performance that may be attributed toinherent organizational deficits (Phelan, Filliter, & Johnson,2011). We did not include a measure of how improvementin narrative proficiency may have generalized to social oracademic skills. We plan to do so in the future.

SummaryThe results of this single-case study demonstrated that

a three-phase narrative intervention program resulted inchanges in overall story complexity, story grammar knowl-edge, and perspective taking in five children with ASD. Theimprovements were generally maintained after interventionended. The intervention was manipulated systematically,the outcome variables were measured by multiple assessorswith good interrater reliability, and the intervention effectswere demonstrated at four different points in time. Therewere clear changes in level between baseline and interven-tion phases for all five participants and changes in trend forfour of the five participants. These findings underscore theimportance of providing external organizational scaffoldsthat were integrated with particular linguistic structuresthat clarified the causal relationships between the events.


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Children were given the opportunity to practice telling co-herent and cohesive stories in phases starting with learningabout story grammar elements with an emphasis on howthey relate to each other. In Phases 2 and 3, children gradu-ally took on more responsibility for integrating macrostruc-ture and microstructure elements, with a clear emphasison overtly marking causal relationships between events inthe story and the character’s responses to those events. Theresults of this study provide evidence of the feasibility ofimplementing a three-phase narrative instruction programwith verbal children with ASD.

AcknowledgmentsThe narrative intervention used in this project was developed

with funds from the Institute for Educational Sciences (IES)awarded to S. Gillam and R. Gillam and from Utah State Univer-sity, Logan, Utah (R324A100063). The authors would like tothank Anne Elsweiler, Emily Chandler, Rebecca Roylance,Sarah Clements, Casey Ragan, Casey Laing, Tanner Price, LoganWoolstenhulme, Ari Watt, Laura Peters, Thomas Christensen,DeVanie Hatfield, Abbie Lewis, Mallory Bond, Camilly Wynn,and the parents and children who participated in this project.Without the dedication and commitment of these faculty, students,and families, this work would not have been possible.

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