Communication Disorders Quarterly

A Systematic Review of Narrative-Based 32(4) 207­–220

© Hammill Institute on Disabilities 2011
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DOI: 10.1177/1525740109353937

Have Language Impairment http://cdq.sagepub.com

Douglas B. Petersen1

Abstract
This systematic review focuses on research articles published since 1980 that assess outcomes of narrative-based language
intervention for preschool and school-age children with language impairment. The author conducted a comprehensive
search of electronic databases and hand searches of other sources for studies using all research designs except
nonexperimental case studies.The results of the studies were converted to a common metric using effect sizes.The review
yielded nine studies that met inclusion criteria.The majority of studies reported moderate to large effect sizes for narrative
macrostructure and microstructure. Although the results of the studies were generally positive, each of the studies had a
limited number of participants, limited experimental control, and considerable variation in the procedures and materials
used. Clinicians should be cautious when interpreting the results of these studies. Narrative intervention is at an emerging
stage of evidence and needs further investigation.

Keywords:
narratives, storytelling, intervention, language impairment

Language intervention with children often focuses on
aspects of conversation. Conversation is a type of dialogic
discourse that involves two or more participants engaged in
cooperative communication (Sacks, Schegloff, & Jefferson,
1974). Due to a mutual social, temporal, and physical con-
text, conversation can involve the use of less precise, infor-
mal oral language. Conversational language, therefore, is
highly contextualized, where the message being conveyed
need not be entirely embedded in the oral language itself.
For example, a conversation between two children could be
transcribed as follows:
That one. This one? Yeah. Let’s go over there and
play with it. Ok. Throw it to me! Oh, I’m so sorry!
Pinch your nose. Hang on. I’ll go get help.
Although the two children conversing in the sample
above understood each other, this conversation would make
little sense to a person not present. Conversational lan-
guage, because of its contextual support, functions quite
well even when simple, ambiguous language is used.
In contrast, narration (storytelling) is primarily a mono-
logic style of discourse that requires one person to convey a
message while others take a lesser expressive role and serve
as listeners. When children use narratives to communicate,
they are required to construct a context for their listener
almost exclusively through language (Snow, 1991). This
is because narratives are usually focused on temporally
removed events that are fully understood only by the narra-
tor. This places a greater demand on the narrator to use
complex, descriptive language. For example, if a child were
to narrate the events of the conversation above to a teacher
who was not present, the narrative might read as follows:
At recess David gave John the red football and they
ran over to the field to play. David told John to throw
the ball, so he threw the ball really hard and hit him
in the face. David got a bloody nose and he was
screaming. John said, “Pinch your nose,” then John
ran and got the teacher.
The differences between the conversational language
sample and the narrative language sample are quite evident.
The narrative language sample contains macrostructural
1
University of Wyoming, Laramie, USA
Corresponding Author:
Douglas B. Petersen, University of Wyoming, College of Health Sciences,
Division of Communication Disorders, Department 3311, 1000 E.
University Avenue, Laramie, WY 82071, USA
Email: dpeter39@uwyo.edu

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208 Communication Disorders Quarterly 32(4)
elements that enhance the general organization of the narra-
tive and more complex, finite linguistic features (micro-
structure) that further increase narrative clarity. The ability
to produce well-formed, clear narratives is founded on rela-
tively advanced linguistic skills.
Given the complexity of language required for narration,
it is not surprising that children with language and learning
disabilities often have difficulty understanding and produc-
ing narratives (Bishop & Adams, 1992; Boudreau &
Chapman, 2000; Fey, Catts, Proctor-Williams, Tomblin,
& Zhang, 2004; Gillam & Johnston, 1992; Greenhalgh &
Strong, 2001; Newman & McGregor, 2006; Scott
& Windsor, 2000). This difficulty with narration can
adversely affect academic progress (Bishop & Adams,
1992; Boudreau & Hedberg, 1999; Gillam & Johnston,
1992). Narration, both written and oral, is used in the school
setting to impart information and assess comprehension
(Petersen, Gillam, Spencer, & Gillam, in press).
Narratives are an important aspect of school curriculum
and a naturalistic means of targeting specific language diffi-
culties. Embedding language intervention within the context
of narration may have many benefits for children who have
language impairment. Teaching children to produce narra-
tives for the specific purpose of improving storytelling can
have academic value. Narratives can also be used as a means
whereby complex language is introduced and practiced.
Treating narratives in this manner shifts the focus of interven-
tion from the production of satisfactory narratives to the pro-
duction of correct language features. By embedding direct
language targets (e.g., morphosyntax) in a narrative context,
children can practice targeted language skills while construct-
ing a meaningful form of communication that is naturalistic.
Narrative-based language intervention is emerging as a
language intervention procedure and clinicians need to be
aware of the degree to which empirical evidence supports
the effectiveness of narrative intervention. Therefore, a sys-
tematic review of the existing research pertaining to narra-
tive intervention for preschool and school-age children with
language or learning disabilities was conducted.
Method
Electronic databases were searched to find appropriate studies.
Various combinations of the following search terms were used:
narrative, discourse, therapy, intervention, narrative interven-
tion, language, impaired, language impaired, storytelling, story
telling, story-telling, and retelling. A total of 3,958 article titles
was reviewed. The specific results of the electronic search
were as follows: Scholar.google.com resulted in 1,240 poten-
tial articles with the terms language intervention and narra-
tive. The databases Medline, CINAHL, Psychology and
Behavioral Sciences Collection, PsychINFO, Pre-CINAHL,
Health Source-Consumer Edition, Humanities Abstracts,
Social Sciences Abstracts, MasterFILD Premier, Academic
Search Premier, and Dissertation Abstracts International
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resulted in 1,442 potential articles using an exhaustive combi-
nation of the search terms listed above. Using the same combi-
nation of search terms, a search using Highwire.org resulted in
1,276 potential articles. The title of each article was read, and
if the title warranted further investigation, the abstract or full
text was reviewed. A total of 56 article abstracts and/or full
texts was reviewed and screened for inclusion criteria. In addi-
tion, the references from those 56 articles were examined,
resulting in an additional 152 article abstracts/full texts that
were reviewed.
Inclusion Criteria for Narrative Intervention Studies
Narrative intervention was defined as an intervention proce-
dure that used oral narratives as a medium whereby lan-
guage-related features were modeled by the clinician and
practiced by the participant. Only studies that employed a
narrative intervention procedure with preschool or school-
age children between the ages of 3 and 21 years who had
language or learning disabilities were included. The severity
of language disability and/or learning disability was defined
and described in the Participants section of each study.
Studies that required only one narrative retelling were not
included because these studies typically described the effect
of differing narrative elicitation procedures on narrative pro-
duction for assessment purposes—intervention was not the
aim of these studies. Procedures using direct reading from a
text as the independent variable were not included. All
research studies conducted from 1980 to 2008 were consid-
ered with the exception of nonexperimental case studies.
Outcome Measures Compared Across Studies
The dependent variables of each study were classified as
relating to narrative macrostructure (expressive and recep-
tive) and narrative microstructure. Macrostructure was
defined according to Stein and Glenn’s (1979) story gram-
mar analysis and Peterson and McCabe’s (1983) episodic
complexity analysis. Microstructure included causal and
temporal subordinating conjunctions, coordinating con-
junctions, adverbs, elaborated noun phrases, cognitive and
linguistic verbs, dialogue, length (e.g., number of clauses,
total number of words [TNW], or number of C-units in a
narrative), and complexity (e.g., syntax, morphosyntax,
mean length of utterance [MLU], and number of different
words [NDW]) (Greenhalgh & Strong, 2001; Nippold &
Taylor, 1995; Strong & Shaver, 1991; Westby, 1999).
Results
A total of nine research studies met the inclusion criteria for
narrative intervention with preschool or school-age chil-
dren with language impairment or learning disabilities (see
Table 1). Effect sizes were calculated when sufficient data
were available. Effect sizes using Cohen’s d (Cohen, 1988)

Table 1. Summary of Narrative Intervention Studies With Preschool and School-Age Children Who Have Language or Learning Disabilities
Study n Participants Design Setting Duration Mnt Gen DV Sig. ES Avg. ES
Davies, Shanks, & 31 t kindergarten pre–post small three 40-min. no no a) RAPT Info a) > .01 a) 1.32 (1.10) macro exp
Davies (2004) group & sessions/ (a + c + e + h)
classroom week for 0.73
8 weeks
EA no control 960 total b) RAPT Grammar b) > .01 b) 0.94 (0.74) microstructure
English group min. c) Bus Story Info c) .008 c) 0.68 (0.44) (b + d + f + g)
d) Bus Story C-Units d) .005 d) 0.75 0.77
e) episode e) .005 e) 0.69
f) number f) > .01 f) 0.92
conjunctions
g) type conjunctions g) > .01 g) 0.66
h) story type h) .01 h) 0.67
Gillam, McFadden, & 4t 9–12 years pre–post small group three 120- no no oral and written NA oral/written oral/written
van Kleek (1995) (third–sixth min.
grades) sessions/
week for
6 weeks
4 c EA control 2,160 total a) naïve judge a) NA/NA macro exp
group min. (b + c + d)
(nonrandom) 1.52/0.24
English b) prop/T-units b) 0.82/–0.44 microstructure (g +
c) episodes c) 2.26/0.43 e + f) –0.97/–0.96
d) multiple d) 1.47/0.74
episodes
e) MLU e) –1.07/–1.05
f) syntax f) –1.08/–1.19
g) causal g) –0.77/–0.64

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conjunctions
Hayward & Schneider 11 t pre-K pre–post small group two 20-min. no no a) story a) .001 a) 1.0 macro exp 1.48
(2000) sessions/ grammar
week;
8–12
sessions
EA 320–480 b) episode level b) .001 b) 1.96
total min.
English
Klecan-Aker, Flahive, & 8t 6–9 years old RCT pre–post individual three 30-min. no no a) number T-units a) no a) NA macro exp (f) 0.95
Fleming (1997) control group sessions/
week for
12 weeks
7 c EA 1,080 total b) number b) .04 b) 1.0 microstructure
min. clauses (b + c + d) 1.33
English c) number words c) < .05 c) 1.2

209
(continued)
 210
Table 1. (continued)
Study n Participants Design Setting Duration Mnt Gen DV Sig. ES Avg. ES
d) number d) < .01 d) 1.8
words/T-unit
e) number e) no e) NA
clauses/T-unit
f) story level f) < .05 f) 0.95
Peña et al. (2006) 14 t first & second pre–post individual two 30-min. no no a) total story score a) no NA NA
(Study 2) grades sessions (b, c, d)
57 c 35% AA English control 60 total min. b) story b) no
group components
32% EA English (nonrandom) c) ideas and c) no
language
30% Latino d) episodes d) no
English/ e) MLU e) no
Spanish f) TNW f) no
g) NDW g) no
h) number clauses h) no
i) number i) no
clauses/CU
Petersen, Gillam, 3t 6–8 years multiple baseline individual 10 90-min. yes yes picture prompt picture prompt
Spencer, & Gillam sessions
(in press) EA 1,090 total a) story grammar a) NA a) 80%, 70%, macro exp (a) 73%
min. episode structure 70% (PNDs)
English b) causality b) NA b) 60%, 60%, microstructure (b)
50% (PNDs) (c + d + e + f + h
+ I + j) 57% PND
0.79
c) temporal adv. c) NA c) 0.67, –0.59, verbal prompt
clauses 0.46
d) adverbs d) NA d) 0.88, 1.5, macro exp 100%

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1.25
e) elaborated noun e) NA e) 0.87, microstructure 67%
phrases 0.89, 1.29
f) mental & linguistic f) NA f) –0.88,
verbs 0.70, 1.15
g) reference g) NA g) NA
cohesion
h) MLU h) NA h) 0.62,
1.22, 0.10
i) TNW i) NA i) 0.02, 1.52, 1.3
j) NDW j) NA j) 0.16, 1.36, 1.53
verbal prompt
a) 100%,
100%, 100%
b) 0%,
100%, 100%

(continued)

Table 1. (continued)
Study n Participants Design Setting Duration Mnt Gen DV Sig. ES Avg. ES
Petersen, Gillam, & 12 school-age alternate treat- small group four 90-min. no no a) INC a) < .05 a) 1.58, 1.02, INC (macro & micro
Gillam (2008) ment pre–post sessions/ 1.34, 0.49, exp)
week for 4 1.53
weeks
1,440 total b) TNL (Exp) b) < .05 b) 1.57 1.19
min. c) TNL (Rec) c) < .05 c) 0.81 TNL
d) TNL (NLI) d) < .05 d) 1.31 macro exp 1.57
macro rec 0.81
Swanson, Fey, Mills, & 10 t second grade pre–post individual three 50-min. no yes gain NA NA
Hood (2005) sessions/ scores
week for 6
weeks
EA no control lab, school, 900 total min. a) NQ: narrative a) yes
group home quality
English b) NDW b) no
c) generalization c) no
d) recalling d) no
sentences
e) nonword e) no
repetition
Tyler & Sandoval (1994) 6t pre-K multiple baseline individual two to three no yes a) MLU NA NA microstructure
45–min. (Note: Only
sessions/ participants with

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week for mild/moderate
12 weeks disabilities
improved
microstructure.)
phonology group 1,080–1,620 b) Brown’s stages
as a control total min.
group
c) morphemes

Note: Effect sizes (ES) calculated using the following methods: a) (M1pre – M1post) – (M2pre – M2post) divided by pooled SD, b) (treatment group mean – control group mean) divided by pooled SD,
c) using ES calculations from F test. Mnt = maintenance; Gen = generalization; Sig. = statistical significance; DV = dependent variable(s); EA = European American; RAPT = Renfrew Action Picture Test;
n = number of participants; t = treatment group; c = control group; MLU = mean length of utterance; macro exp = expressive macrostructure; macro rec = receptive macrostructure; RCT =
Randomized Control Trial; AA = African American; PND = Percentage of over-lapping Data Points; TNW = total number of words; NDW = number of different words; INC = Index of Narrative
Complexity; TNL = Test of Narrative Language; NLI = Narrative Language Index.

211
212 Communication Disorders Quarterly 32(4)

Table 2. Critical Appraisal Questions for Group Research Studies

Control group Did the study include a control group and one or more treatment groups?
Random assignment Were the participants randomly assigned to the treatment and control groups?
Participants Did the authors provide information about the age, gender, race, ethnicity, socioeconomic status, speech
and language abilities, and/or cognitive status of the children who participated in the study?
Initial group similarity Were the groups the same in all important ways except for the treatment under investigation?
Blinding Did the individuals who conducted the assessments and analyzed the data know which groups (treat-
ment, comparison, or control) the participants were assigned to?
Measures Were the formal and informal measures used to assess the treatment outcomes valid and reliable?
Statistical significance Did the authors report p values (the probability that a difference between the mean scores of two or
more groups would not occur by chance alone) that were less than .05?
Practical significance Did the authors report Eta squared values (percentage of variance accounted for) or standardized d
values (number of standard deviations of difference between pre- and posttesting or between groups)
that were at lest moderately large? If not, could moderately large values be calculated from the data
that were provided in the article?

Note: Adapted from Gillam and Gillam (2006).

were calculated for studies that employed a no-treatment
control group. When a study did not include a no-treatment
control group, effect sizes were calculated by comparing
the differences between pretest and posttest scores of the
treatment and alternate treatment groups (Cirrin & Gillam,
2008). In addition, effect sizes from gain scores and F tests
were calculated if necessary (Thalheimer & Cook, 2002).
When effect sizes are calculated from gain scores, and no
control group is available for comparison, considerable
caution must be taken in interpreting the validity of the
effect sizes. Multiple threats to internal validity potentially
confound the study outcomes.
Not all studies included in the review were of equal qual-
ity. Each of the nine studies was coded for internal and exter-
nal validity using the methods proposed by Gillam and Gillam
(2006; see Table 2) and Horner et al. (2005; see Table 3). The
results of the study quality appraisals are found in Tables 4
and 5. Generally speaking, the greater the number of appraisal
points awarded a study, the greater confidence one can have in
the causal relationship between the intervention and study
outcomes. The nine studies reviewed in this article received
an average of 4.8 out of 8 appraisal points (ranging from 2 to
7). Low to moderately high confidence can be placed in the
results of the studies reviewed. Table 6 outlines the different
narrative intervention procedures used in each study. The nar-
rative intervention procedures were classified as having a
focus on (a) expressive narrative macrostructure, (b) receptive
narrative macrostructure, and (c) microstructure.
Summary of Narrative Intervention Studies
The nine studies under review are summarized below
according to the date of publication.
Tyler and Sandoval (1994) assessed the phonology and
language production of six preschool children with both pho-
nological and language impairments after assigning them to
one of three different treatment conditions: (a) elicited imita-
tion and contrasted minimal pairs of phonological targets
(phonological intervention), (b) indirect narrative language
intervention (narrative intervention), or (c) combined inter-
vention using both treatments (combined intervention). The
participants in the three treatment groups differed in severity
of disability. The children in the narrative intervention group
were classified as having more severe disabilities than the
children in the phonological intervention and combined inter-
vention groups. The two groups of children assigned to the
conditions involving narrative intervention (narrative inter-
vention and combined intervention) were asked to listen to
narratives containing multiple exemplars of morphosyntatic
targets and then retell those narratives with clinician support
to a naïve listener. The two participants assigned to the phono-
logical intervention group were asked to repeat target pho-
nemes. Forty-five minute, individual therapy sessions were
conducted in a clinic two to three times a week for 12 weeks.
Two 6-week intervention cycles were planned, however, one
participant assigned to the narrative intervention treatment
withdrew from the study after the first 6-week cycle. All six
participants across the three treatment conditions increased
their MLU in spontaneous language samples. Likewise, all
six participants demonstrated an increase in morphosyntax
usage during intervention sessions. It is interesting that the
two participants who were assigned to the narrative interven-
tion group were the only children who did not show morpho-
syntactic gains in postintervention spontaneous language
probes. Effect sizes for the microstructure variables could not
be calculated. Given that the groups demonstrated different
levels of severity of delays prior to intervention and outcomes
for each group mimicked initial levels, little can be concluded
from these results. The study quality assessment rating was 2
for this study, suggesting that very little confidence can be
placed in the causal relation between the intervention and
study outcomes.

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Petersen 213

Table 3. Critical Appraisal Questions for Single Subject Research Studies

Description of participants and settings Were the participants described with sufficient detail?
Was the process for selecting participants described with replicable precision?
Were the critical features of the physical setting described with replicable precision?
Dependent variable Were the dependent variables described with operational precision?
Were the dependent variables quantifiable?
Were the dependent variables valid and described with replicable precision?
Were the dependent variables measured repeatedly over time?
Was interobserver agreement reliability at least 80%?
Independent variable Was the independent variable described with replicable precision?
Were the independent variables systematically manipulated and under the control of the
experimenter?
Fidelity of treatment implementation data?
Baseline Were there repeated measures indicating a predictable pattern during baseline?
Were the baseline conditions described with replicable precision?
Blinding Were the individuals who conducted the assessments and analyzed the data unaware of
subject identity, the baseline, treatment, and follow-up conditions?
Internal validity Did the design provide at least three demonstrations of experimental effect at three
different points in time?
Did the design control for common threats to internal validity?
Did the results document a pattern that demonstrated experimental control?
External validity Were the experimental effects replicated across participants, settings, or materials?
Social validity Was the dependent variable socially important?
Was the magnitude of change in the dependent variable socially important?
Was the implementation of the independent variable practical and cost-effective?
Was the intervention implemented using typical intervention agents in typical physical and
social contexts?
Note: Adapted from Horner et al. (2005).

Table 4. Group Study Quality Appraisal

Control Random Group Dependent Statistical Practical Appraisal
Study Group Assignment Participants Similarity Blinding Variable(s) Significance Significance Points
Gillam et al. (1995) yes yes yes no yes no yes yes 6 moderate
Klecan-Aker, Flahive, & yes yes yes yes no no yes yes 6 moderate
Fleming (1997)
Peña et al. (2006) yes no yes yes yes yes no no 5 low/moderate
Petersen, Gillam, & no yes yes yes yes yes yes yes 7 moderate/high
Gillam (2008)
Tyler & Sandoval (1994) yes no yes no no no NA NA 2 low

Table 5.  Single Subject Study Quality Appraisal

Dependent Independent Internal External Social Appraisal
Study Description Variable Variable Baseline Blinding Validity Validity Validity Points
Davies, Shanks, & Davies (2004) no yes yes no no no no yes 3 low
Hayward & Schneider (2000) yes no no no yes no no yes 3 low
Petersen, Gillam, Spencer, & yes yes yes yes yes yes no yes 7 moderate/high
Gillam (in press)
Swanson, Fey, Mills, & Hood (2005) yes yes yes no no no no yes 4 low
Note: Adapted from Horner et al. (2005).

Gillam, McFadden, and van Kleek (1995) compared the enrolled in a story-oriented narrative intervention program
effects of two different language intervention procedures on and four children were enrolled in a language skills program
the oral and written narratives produced by eight 9- to 12-year- (treated as a control group for this review). The narrative pro-
old children with language impairment. Four children were gram revolved around children’s literature and the retelling

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214 Communication Disorders Quarterly 32(4)

Table 6. Narrative Intervention Procedures and Materials

Microstructure:
Study Macrostructure: Expressive Macrostructure: Receptive Literate/Non-Literate
Davies, Shanks, & Davies (2004) Narrative Production/Retelling answer “wh” questions NA
peer teaching cue cards
puppets
role-play
think-aloud
recorded narratives
Gillam, McFadden, & van Kleek (1995) Narrative Production/Retelling reflective questioning temporal relations
causal relations
teacher/peer modeling
inferential/factual questions
semantic mapping
role-play
songs
games
pictures
hand-drawn pictures
semantic maps (for writing)
book making
children’s literature
Hayward & Schneider (2000) Narrative Production/Retelling comprehension monitoring temporal relations
causal relations
wordless picture books
close procedures
vocabulary building
role-play
cue cards
sorting
pictures/photos
Klecan-Aker, Flahive, & Fleming (1997) Narrative Production/Retelling NA syntax
sequence cards
photos
hand-drawn pictures
multiple choice resolution
close procedure
Peña et al. (2006) Narrative Production/Retelling NA Narrative Production/
Retelling
wordless picture books wordless picture books
story grammar temporal markers
episode structure causality
Petersen, Gillam, & Gillam (2008) Narrative Production/Retelling answer “wh” questions causal relations
wordless picture books
icons/cue cards
photos
hand-drawn pictures
story grammar
episode structure
Petersen, Gillam, Spencer, & Gillam Narrative Production/Retelling answer “wh” questions causal relations
(in press ) temporal relations
wordless picture books
icons/cue cards
photos
hand-drawn pictures
story grammar
episode structure

(continued)

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Petersen 215
Table 6. (continued)
Study Macrostructure: Expressive
Swanson, Fey, Mills, & Hood (2005) Narrative Production/Retelling
wordless picture books
single photo/picture
hand-drawn pictures
story grammar
episode structure
sequencing
sentence repetition
Tyler & Sandoval (1994) NA
and generation of oral and written narratives using various
props and activities. The language skills program principally
consisted of form-focused direct instruction in spoken and
written language skills. Oral and written narratives produced
by the narrative intervention group were reported to contain
more complex macrostructure in comparison with the lan-
guage skills control group. In contrast, the comparison, lan-
guage skills group produced oral and written narratives with
more advanced microstructure (causal/temporal relations,
syntax, MLU). The average effect sizes for oral and written
narrative macrostructure were 1.52 and .24, respectively. The
average effect sizes for oral and written microstructure were
–.97 and –.96, respectively. The quality of narratives was also
evaluated by blinded examiners, with 50% of the oral narra-
tives and 25% of the written narratives produced by the chil-
dren in the whole language group judged to be good stories,
whereas 0% and 12%, respectively, of the stories produced by
the language skills group were considered good stories, lend-
ing some support to the possibility that macrostructure is
more reflective of narrative quality than microstructure. The
study appraisal score was 6, suggesting that a moderate degree
of confidence can be placed in the causal (positive and nega-
tive) effect of the intervention.
Klecan-Aker, Flahive, and Fleming (1997) randomly
assigned eight children with language impairment to a narra-
tive intervention treatment group and seven children with
language impairment to a no-treatment control group. The
researchers investigated the narrative and linguistic com-
plexity in narratives produced by the children after receiving
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Microstructure:
Macrostructure: Receptive Literate/Non-Literate
NA Narrative Production/
Retelling
dialogue
morphosyntax
conjunctions
subordinationcomplex
verbs
postmodification of nouns
NA Narrative Retelling
Group A
focused stimulation
modeling
paraphrasing
expansion
recasting
naïve listeners
Group B
direct phonology/
morphophonemes
(plural/past tense)
16 weeks of small group instruction that focused on story
grammar (macrostructure) and syntactic complexity (micro-
structure). Outcomes of the treatment program indicated that
the children receiving the narrative intervention signifi-
cantly improved their narrative macrostructure and increased
the number of clauses per narrative when compared with the
no-treatment control group. The average narrative macro-
structure effect size was .95 and the average narrative micro-
structure effect size was 1.33. Both effect sizes are considered
large and indicate that the narrative intervention had a mean-
ingful effect on the children’s narrative ability. In addition,
the study appraisal score was 6, lending a moderate degree
of validity to the causal nature of the intervention.
Hayward and Schneider (2000) implemented narrative
intervention with an emphasis on story grammar to 13 pre-
school children with language impairment. All children
attended a language-based, early childhood classroom
located in a rehabilitation hospital, and they participated in
small intervention groups (2–3) twice a week for 20 minutes.
Although narratives were central to the ongoing classroom
curriculum, story grammar elements were not directly tar-
geted outside of the experimental intervention. Pictures from
the book Oops by Mercer Mayer (1977) and cue cards were
used to aid the children in identifying, sorting, reorganizing,
and sequencing story grammar components. An AB single
subject design was implemented with half the group receiv-
ing two baseline probes and half the group receiving four
baseline probes. Group pretest to posttest gains reflect a
statistically significant difference for story grammar and
216 Communication Disorders Quarterly 32(4)
episode level. Based on the single subject graphical displays,
12 out of 13 participants showed improvements, with the
majority of participants demonstrating substantial gains (i.e.,
high percentage of nonoverlapping data points) after only
eight intervention sessions. The average effect size for narra-
tive macrostructure was 1.68. Although causal and temporal
relations were targeted during intervention, those variables
were not measured as dependent variables. The AB design
limits confidence in a causal relationship, and because the
assessment stories were also used during intervention, the
intervention effect cannot be isolated. The study received a
study quality appraisal score of 3, indicating that multiple
threats to the validity of the study findings are plausible.
Davies, Shanks, and Davies (2004) assessed the narra-
tive skills of 31 kindergarten children identified by teachers
as having language difficulty after participating in three,
40-minute narrative intervention sessions per week over 8
weeks. Results revealed significant differences between all
pre- and posttesting measures, with the children improving
narrative macrostructure (story grammar and episodic com-
plexity) and microstructure (additive, temporal, and causal
conjunctions, syntax, and number of C-units). The average
effect sizes for each of the dependent variables were moder-
ate. The Davies et al. (2004) study was a simple pre–post
design that received a study appraisal score of 3. This low
quality appraisal score suggests that limited confidence
should be placed in the causal nature of the intervention.
Swanson, Fey, Mills, and Hood (2005) analyzed the nar-
ratives of 10 children (ages 6–8) for various aspects of nar-
rative macrostructure and microstructure after implementing
a 6-week narrative-based language intervention program. It
was reported that 8 out of the 10 children who participated
made clinically significant improvement on measures
of narrative macrostructure. However, pre–post-narrative
microstructure data concerning NDW, syntax, and sentence
imitation tasks were nonsignificant. Insufficient data were
reported for the calculation of effect sizes. The study
appraisal score was 4, suggesting that a low level of confi-
dence can be placed on the validity of the study outcomes as
a function of the narrative intervention.
Peña et al. (2006) evaluated the influence of two 30-
minute narrative intervention sessions on the macrostruc-
ture of narratives produced by 14 children with language
impairment. A typically developing group of 27 children
also participated in the intervention (treated as a control
group in this review) and a group of 30 children with lan-
guage impairment received no treatment (also treated as a
control group). Children with language impairment
assigned to the language impairment treatment group
showed no greater increase in narrative macrostructure
from pretest to posttest than the typically developing chil-
dren in the no-treatment control group, suggesting that very
short-term narrative intervention is not beneficial for
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improving narrative macrostructure for children with lan-
guage impairment. The study appraisal score was 5 out of 8
possible points, suggesting that a low-moderate degree of
confidence can be placed in the validity of the findings. The
nonsignificant gains in narrative macrostructure are not sur-
prising considering the limited duration of the intervention
(two individual 30-minute sessions).
Petersen, Gillam, and Gillam (2008) conducted a pre-
liminary investigation to determine the effect of narrative
intervention on the macrostructure and microstructure
of school-age children with language impairment. Twelve
children (ages 6 years 4 months to 9 years 1 month; M = 8
years 2 months) with language impairment were assessed
using the Index of Narrative Complexity (INC; Petersen
et al., 2008) at 1-month intervals (pretest 1 in early June,
pretest 2 in early July) before treatment. During the treat-
ment phase, the children attended four 90-minute narrative
language intervention sessions each week for 4 weeks. The
participants were tested again immediately after the treat-
ment (posttest). The Test of Narrative Language (TNL;
Gillam & Pearson, 2004) was administered after treatment
to provide evidence of narrative language growth and to
evaluate criterion validity of the INC. The results indicated
that children’s narration did not change appreciably during
the month that they were not enrolled in school and were
not receiving intervention. Following intervention, the INC
scores, which reflect aspects of narrative macrostructure
and microstructure, increased significantly. This same pat-
tern of results was obtained for each of the INC measures
and for the TNL. Cohen’s d effect size calculations for dif-
ferences between pretest 2 and posttest (the treatment phase
of the study) yielded moderate to large effect sizes. The
study appraisal score was 7 out of 8, suggesting that moder-
ately high confidence can be placed in the results.
Petersen et al. (in press) investigated the effect of narra-
tive intervention on the macrostructural and microstructural
language features of the oral narratives produced by three
children, ages 6 to 8 years, with developmental disabilities
and comorbid receptive and expressive language impair-
ment. The three participants engaged in 10 60-minute indi-
vidual narrative intervention sessions following staggered
baseline trials. Assessment probes eliciting picture- and ver-
bally prompted narratives were recorded and analyzed. All
three children demonstrated considerable gains in episodic
construct and the use of story grammar (macrostructure) and
causality (microstructure), with moderate to large effect sizes
based on percentage of nonoverlapping data points.
Additional gains were noted in areas of microstructure not
specifically targeted during intervention such as the use of
adverbs, elaborated noun phrases, mental/linguistic verbs,
pronomial reference cohesion, MLU, TNW, and NDW.
Gains were seen both in picture-prompted narratives that
were the direct focus of intervention and in verbally prompted
Petersen 217
narratives, a measure of generalization. Follow-up data were
collected 8 months after intervention, which indicated some
maintenance of skills over time. This study received a quality
appraisal of 7, indicating that a moderate-high degree of con-
fidence can be placed in the effect of the intervention on the
dependent variables measured.
Discussion
Narrative Intervention Procedures and Materials
There appeared to be limited overlap between the narrative
intervention procedures and materials used in the nine studies
reviewed (see Table 6). Each of the studies required partici-
pants to retell and/or generate narratives, yet all other
described procedures were unique to individual studies,
although focused stimulation (Leonard, Camarata, Rowan, &
Chapman, 1982), vertical structuring (Schwartz, Chapman,
Terrell, Prelock, & Rowan, 1985), and incidental teaching
techniques (Hart & Risley, 1975) were common themes.
There was more overlap in the use of materials: Six of the
nine studies used single photos or pictures to elicit narratives
and five used wordless picture books. Five studies had the
children draw representative pictures of intervention stories.
Three of the studies used icons or cue cards and role-playing.
All other materials were unique to the individual studies.
Macrostructure
The effect sizes for narrative macrostructure were moderate
to large, ranging from .73 to 1.57, yet there was no clear con-
nection between the extent of positive macrostructure out-
comes and the different intervention procedures and materials
used. An emphasis on repeated narrative retelling and narra-
tive generation was the only common procedure among the
narrative intervention studies. There is an expressive lan-
guage factor inherent in both story retelling and generation,
and it may be that expressively producing modeled narratives
is key to narrative macrostructure development. Apart from
the repeated retelling and generation of modeled stories, all
other materials and procedures may be superfluous, not caus-
ally related to macrostructure improvement. Thus, narrative
intervention purposed to improve macrostructure could be
simple procedurally. This is not to suggest that methods and
items of interest should not be used to capture the attention of
children involved in the narrative intervention sessions.
Children’s motivation and attention are a foundational requi-
site for focused, intensive intervention. In addition, it is
important to acknowledge the role of the clinician in narra-
tive intervention. Although each study offered limited infor-
mation concerning the degree and type of scaffolding and
support that the clinicians offered during intervention, it was
clear that the clinicians played an active role in shaping the
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narratives that the children produced. It is, nevertheless,
important to isolate the causal factors of a particular interven-
tion so that the clinician’s time and energy (and expense) are
focused on the appropriate procedures.
Microstructure
Even though all of the studies but one (Davies et al., 2004)
reportedly focused on some aspect of narrative microstruc-
ture, intervention procedures were typically described in
little detail. Only Petersen et al. (in press) offered insight
concerning the frequency with which literate microstructure
was targeted. These authors purposefully emphasized the
microstructure features of causality and temporal relations
while also measuring those features as dependent variables.
Effect sizes for microstructure resulting from their study
were moderate to large. In contrast, the Gillam et al. (1995)
study reported strongly negative microstructure results for
their narrative intervention group. The reason for the nega-
tive results reported by Gillam et al. and positive results
reported by Petersen et al. could be attributed to the degree
to which narrative microstructure was explicitly targeted
during intervention. During the Gillam et al. study, narrative
microstructure was never specifically targeted for the narra-
tive intervention group, and the control group, which had
considerably higher gains in narrative microstructure, par-
ticipated in an intervention founded on direct, explicit
instruction. Petersen et al. strongly emphasized causality,
using a direct, explicit instructional approach in their narra-
tive intervention. For example, it was reported that causality
was emphasized by a clinician during one narrative inter-
vention session 63 times in 45 minutes.
Although Petersen et al. (in press) specifically tar-
geted causality in each narrative intervention session, they
did not specifically target other aspects of microstructure
such as adverbs, elaborated noun phrases, mental and lin-
guistic verbs, or reference cohesion. The authors did, how-
ever, measure those variables because of the nature of their
intervention procedures. They found that most measures
of microstructure increased once intervention was imple-
mented, with moderate to large effect sizes. Whereas the
Gillam et al. (1995) and Petersen et al. results indicate that
certain aspects of microstructure such as causal and temporal
relations are best acquired through direct, explicit instruc-
tion, it appears possible that the intensive exposure to narra-
tives that contain various microstructure features may be
sufficient to incidentally improve those features in narration.
Three other studies reportedly focused on the micro-
structure features of causality and temporal relations, how-
ever, those features were not measured as dependent
variables. More research is needed to clarify the extent to
which these important microstructure features must be
directly targeted in narrative intervention.
218 Communication Disorders Quarterly 32(4)
Of the six studies that measured the microstructure fea-
tures related to length and complexity, all but Gillam et al.
(1995) and Swanson et al. (2005) reported moderate to large
effect sizes. Reasons for the Gillam et al. negative results
have already been suggested (e.g., limited direct instruction),
and although Swanson et al. targeted multiple microstructure
features during intervention, only the number of different
words in narratives was measured as a dependent variable.
Duration and Intensity of Narrative Intervention
Only the Peña et al. (2006) study did not show a meaningful
effect size for any of the dependent variables, and that is
likely due to the limited amount of intervention that the par-
ticipants received (60 total minutes). Most of the other stud-
ies demonstrated moderate to large effect sizes for narrative
macrostructure and/or narrative microstructure while imple-
menting narrative intervention individually or in a small
group from 320 to 2,160 total minutes of intervention. The
results of the studies reviewed (Peña et al., 2006, the excep-
tion) did not significantly correlate with the duration or
intensity of narrative intervention sessions each week. It can
be tentatively concluded that children with language impair-
ment need more than 60 minutes of narrative intervention to
improve their narrative abilities.
Generalization and Maintenance
of Narrative Intervention
If narrative intervention is to be considered effective, it must
be demonstrated that the skills acquired during intervention
can be performed without artificial supports over time
(maintenance) and that those skills will transfer to real-
world situations (generalization). Only Petersen et al. (in
press) investigated the maintenance of narrative skills,
with mixed results. Two of the three participants showed
some maintenance of skills over time, whereas the third par-
ticipant refused to produce any narratives during the mainte-
nance phase of the study. The Swanson et al. (2005) study
examined generalization, yet the results were nonsignifi-
cant, suggesting that the narrative retelling procedures did
not readily transfer to the spontaneous production of narra-
tives. The Petersen et al. study also investigated the extent to
which the narrative intervention would generalize to sponta-
neous language. They found that for most macrostructure
and microstructure measures, generalization was noted.
Differences between the Petersen et al. and Swanson et al.
studies may offer insight as to why generalization occurred
only in the Petersen et al. study. Petersen et al. targeted nar-
rative macrostructure and microstructure during interven-
tion at more than twice the rate of Swanson et al., which may
have contributed to the generalization of skills. It is also fea-
sible that the generalization of some skills found in the
Petersen et al. study occurred because of the systematic, pur-
poseful introduction and removal of supports and prompts
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that led to independent narrative retellings at the end of each
intervention session. The results of those studies that focused
on generalization and maintenance are not definitive, and
further investigation concerning these important aspects of
language acquisition is necessary.
Transfer of Narrative Proficiency
to Academic Success
One of the theoretical underpinnings to narrative interven-
tion is that narratives serve as a bridge from oral language to
written language (Westby, 1985). Because of the decontex-
tualized, literate nature of narratives, it is possible that narra-
tive proficiency will transfer to other academic skills such as
writing and reading comprehension. The Gillam et al. (1995)
study was the only one to examine the extent to which nar-
rative intervention facilitated progress in written composi-
tion. These researchers found a small mean effect size with
macrostructure and a large negative mean effect size with
microstructure when analyzing written narratives. Recall
that the control group in the Gillam et al. study received
explicit, direct language instruction (oral and written),
whereas the treatment group received a more generalized
narrative intervention approach. The results from the Gillam
et al. study indicate that a general narrative intervention
approach may best facilitate macrostructural aspects of writ-
ten narration, whereas direct, explicit instruction may better
facilitate the development of microstructural features of
written narratives. Future narrative intervention research
should explore the degree to which narrative intervention is
beneficial in enhancing children’s writing, reading compre-
hension, and other academic skills.
Population Sample
Whereas the narrative intervention studies reviewed in this
article focused on children with language impairment, eight
out of nine exclusively included English-speaking, European
American children attending preschool through sixth grade.
The only exception is the brief Peña et al. (2006) study that
included mixed ethnicity. No research to date has investi-
gated the effects of sustained narrative intervention on the
macrostructure and microstructure of narratives produced
by children with language impairment who are culturally
and linguistically diverse, or in the seventh grade or higher.
Furthermore, no study that was reviewed included more
than 31 participants in the treatment group, and most studies
included fewer than 10 participants. This relatively homoge-
neous, limited number of participants reduces the external
validity of the research findings.
Social Validity
Narratives are produced from a very young age to convey infor-
mation, and narrative ability contributes to social and academic
Petersen 219
success. There is considerable social validity to improving
narrative skills. Both Gillam et al. (1995) and Petersen et al. (in
press) asked independent listeners to rate the quality of the nar-
ratives produced by their participants. In each case, the stories
produced by children who had received narrative intervention
were rated higher. Whereas the participants in the study con-
ducted by Petersen et al. demonstrated gains in narrative mac-
rostructure and narrative microstructure, the participants
assigned to the narrative intervention condition in the Gillam
et al. study improved only their narrative macrostructure. These
findings may suggest that it is primarily narrative macrostruc-
ture that contributes to perceived narrative quality.
Summary/Further Research
A comprehensive review of the research on narrative inter-
vention with children who have language impairment
revealed that narrative intervention with repeated story retell-
ings and a focus on narrative macrostructure may be suffi-
cient to facilitate a significant improvement in both narrative
macrostructure and some aspects of narrative microstructure.
However, the majority of the studies reviewed had a limited
number of participants and were considered lower quality.
Caution should be taken when attributing the study outcomes
to the intervention applied. Most of the studies included par-
ticipants who were monolingual, English-speaking European
American. Cultural and linguistic diversity is a factor that has
not been considered. All of the studies that implemented
intervention for 320 total minutes or longer reported moder-
ate to large effect sizes on some aspects of narration. Only
one study did not result in significant improvement in narra-
tive proficiency, and that study implemented narrative inter-
vention for only 60 minutes. Furthermore, only two studies
probed for the generalization of narrative skills acquired dur-
ing intervention to the spontaneous production of narratives.
Only one study reported data on maintenance of narrative
skills following intervention, with mixed results. Thus far,
only one study has investigated the extent to which narrative
proficiency transfers to other language-related academic
skills such as writing.
The results of the research included in this review warrant
further investigation into the effects of narrative intervention
on the narrative macrostructure and microstructure of
children who have language impairment. More research is
needed to establish the efficacy and effectiveness of narra-
tive-based language intervention. In the meantime, clinicians
can continue to treat narratives as a functional language tar-
get and as a medium whereby language features are modeled
and practiced. Clinicians should provide multiple opportuni-
ties for participants to practice retelling and generating model
narratives and, when specifically targeting microstructure,
strategically model and elicit correct language forms with
considerable intensity. Clinicians should carefully monitor
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the progress of their clients by taking frequent, careful data
and checking for the transfer of language features in sponta-
neous narrative and conversational discourse.
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The author received no financial support for the research and/or
authorship of this article.
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About the Author
Douglas B. Petersen, PhD, CCC-SLP, currently teaches and con-
ducts research in the Division of Communication Disorders at the
University of Wyoming. His interests include narrative assessment
and intervention and the identification of early literacy difficulty in
culturally and linguistically diverse populations.