815736

research-article2018
CLT0010.1177/0265659018815736Child Language Teaching and TherapyDawes et al.

Article

Child Language Teaching and Therapy

2019, Vol. 35(1) 39­–54
A randomized controlled trial of © The Author(s) 2018
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DOI: 10.1177/0265659018815736
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intervention for young children journals.sagepub.com/home/clt

with developmental language

disorder

Emily Dawes, Suze Leitão, Mary Claessen

and Robert Kane
Curtin University, Australia

Abstract
Although children with developmental language disorder demonstrate poor inferential
comprehension, few studies have evaluated the effect of interventions to improve inferencing.
This study aimed to investigate the efficacy of a small-group intervention designed to improve
oral inferential comprehension of narrative discourse. Thirty-seven 5- to 6-year-old children
with developmental language disorder participated. The participants were randomly allocated
to the oral inferential comprehension (IC) intervention or a control phonological awareness
(PA) intervention. Small-group sessions took place twice a week over 8 weeks. Participants
were assessed on narrative comprehension and phonological awareness skills pre- and post-
intervention, and after a maintenance period of 8 weeks. Compared to the control PA group,
the participants in the IC group demonstrated a significant increase in inferential comprehension
scores from pre- to post-intervention, which was maintained over time. In addition, the IC group
scored significantly higher than the PA group for inferential comprehension on a post-intervention
generalization measure. There was no significant difference between the two groups for literal
comprehension scores at any assessment point. The results demonstrate that the small-group
intervention was effective at improving inferential comprehension of narratives in 5- to 6-year-
old children with developmental language disorder. Additionally, generalized improvement was
shown across the narrative context, and improvements were maintained two months following
the intervention.

Keywords
book sharing, comprehension, developmental language disorder, inferencing, inferential
comprehension, intervention

Corresponding author:
Emily Dawes, Curtin University, GPO Box U1987, Perth, Western Australia, 6845, Australia.
Email: emily.dawes@postgrad.curtin.edu.au
40 Child Language Teaching and Therapy 35(1)

I Introduction
Inferential comprehension involves the ability to go beyond what is explicitly said by making
links, whereas literal comprehension involves the ability to understand information which has been
explicitly stated or seen (Bishop and Adams, 1992; van Kleeck et al., 2006). Inferencing is particu-
larly important for understanding the whole, or ‘gist’, of a text (Bishop, 2014). Inferences thus
enable the listener or reader to create a more detailed and accurate understanding of a text, with
some inferences establishing coherence at a local level, and others at a more global level. More
local, coherence, inferences are vital to understand the meaning of a text, as they add important
information that is not explicit. In contrast, elaborative inferences add quality by enriching the
context, but are not essential to understanding the discourse (Barnes et al., 1996).
Comprehension of discourse, such as narratives, involves both bottom-up and top-down pro-
cessing, as the listener must process the story meaning, and integrate the incoming message with
previously stored knowledge. Van Dijk and Kintsch (1983) proposed a model of written discourse
comprehension that can be applied to children’s understanding of oral narratives. Initially, the
reader (or listener) must comprehend the individual words, known as the literal or ‘surface’ repre-
sentation. As this surface level representation decays, what remains is the textbase, which is the
online representation of meaning formed by connecting propositions and making inferences within
the text. The highest level of discourse comprehension is the situation model, reflecting top-down
processing and the activation of knowledge related to the text to create a mental model of the dis-
course. As texts are generally not fully explicit, inferences are required to create both the textbase
and situation model (Kintsch and Rawson, 2005).
From an early age, children are exposed to narrative discourse through book sharing, at home
and at school. In the context of book sharing, a useful framework is described by van Kleeck
(2008), who identified three broad types of inferences made by young children. Causal inferences,
the most common type, relate directly to story grammar and involve linking information within or
across texts or with prior knowledge, making predictions, and inferring feelings, attitudes, and
motives. Evaluative inferences involve judgements of morality or convention, while informational
inferences involve providing information on setting (when it is not explicitly stated), defining
words from given information, and elaborating on information using prior knowledge (van Kleeck,
2008). These types of inference are essential for the coherence of information in a discourse, and
may act to enrich comprehension of the discourse through integration with general knowledge
(Cain et al., 2004; van Kleeck, 2008). As such, if an individual has poor inferential comprehension,
they may miss or attach the wrong ‘gist’ to a discourse, which will impact significantly on language
comprehension, and in turn on their overall communicative competence.

1 Development of oral inferential comprehension

Oral inferential comprehension develops gradually from the age of three (Barnes et al., 1996;
Filiatrault-Veilleux et al., 2016). Within the context of narrative discourse, for example, children
aged 3 to 5 improve in their ability to respond appropriately to more abstract questions over time
(Blank et al.,1978a). More recently, Filiatrault-Veilleux et al. (2016) investigated the developmen-
tal progression of inferential comprehension of narratives in typically developing French-speaking
children aged 3 to 6 years. Participants answered comprehension questions embedded in a narra-
tive (on an iPad app) which targeted causal inferences related to story grammar elements (problem,
internal response/feelings, prediction, character goals and attempts, and resolution). The children’s
ability to respond appropriately to all types of inferential questions, and the quality of the responses
provided, improved gradually with age. The 3- to 4-year-olds provided appropriate answers to
Dawes et al. 41

approximately half of all types of inferential questions (41% to 53%), with an increase for the 4- to
5-year-olds (63% to 74%), and again for the 5- to 6-year-olds (75% to 85%) (Filiatrault-Veilleux
et al., 2016). The two older age groups were significantly better than the 3- to 4-year-olds at mak-
ing inferences related to the problem, internal response, and prediction, while the 5- to 6-year-olds
were better than both the younger age groups at inferences related to the character’s goal, attempts,
and the resolution. Variance (within participants and inference types) decreased with age, indicat-
ing consolidation of inferential comprehension skill within the narrative context (Filiatrault-
Veilleux et al., 2016).

2 Inferencing in children with developmental language disorder

It has been well documented that children with developmental language disorder (DLD) have
weaker inferential comprehension skills than age-matched and non-verbal IQ-matched peers
(Bishop and Adams, 1992; Weismer, 1981). These findings have been confirmed by more recent
studies of children with DLD, aged 6 to 7 years (Dodwell and Bavin, 2008), 6 to 11 years (Norbury
and Bishop, 2002; Adams et al., 2009), and 11 years (Botting and Adams, 2005). The findings sup-
port experiences in clinical practice that children with DLD demonstrate poor inferential compre-
hension, particularly of narrative discourse.
The ability to form inferences effectively and efficiently is not only necessary for children’s
learning and participation in the early school years, it is also crucial for later reading comprehen-
sion, and academic achievement (Cain and Oakhill, 2007; van Kleeck, 2008). Poor inferential
comprehension can have a significant impact on a child’s participation in social and learning situ-
ations, such as understanding conversations and play with friends, as well as participating in oral
and written classroom discourse, an important bridge to literate language (van Kleeck, 2008).
Inferential comprehension has been found to be a significant predictor of later reading comprehen-
sion (Silva and Cain, 2015), as well as of later narrative retelling and oral comprehension (Lepola
et al., 2012). As such, oral inferential comprehension is often the focus of intervention by speech
and language therapists for children in the early school years.

3 Discourse level interventions and comprehension

The impact of shared book reading on vocabulary and narrative development has been investigated
in young typically developing children, with few studies specifically investigating the impact on
language comprehension. While results are promising, those studies which assessed comprehen-
sion generally investigated overall comprehension rather than specifically investigating inferential
and/or literal skills.
Following a narrative retelling (macrostructure) intervention, 5-year-old typically developing
children showed significant improvements in narrative comprehension and retelling, compared to
a control intervention group (who drew pictures of stories) (Morrow, 1985). Similarly, Paris and
Paris (2007) found significantly greater improvement in the inferential and literal comprehension
of wordless picture books in a group of 6- to 7-year-old children who received a 5-week whole-
class narrative strategy instruction (involving narrative retelling and comprehension) compared to
a control group. The intervention benefits were similar across participants, regardless of pre-inter-
vention literacy and language abilities (Paris and Paris, 2007).
In terms of book sharing interventions, Collins (2016) investigated the effect of discussion after
book reading with 70, 4- to 5-year-old typically developing Portuguese-speaking children, who
were paired on receptive vocabulary scores. A child from each pair was randomly assigned to
either an intervention or control group, both involving repeated reading (in English) of three
42 Child Language Teaching and Therapy 35(1)

different books in small groups. Discussion after hearing the story was either literal or inferential,
while the control group simply heard each book read. The inferential-only discussion group showed
significantly better literal and inferential comprehension of stories, compared to the literal-only
discussion and control groups (Collins, 2016).
Spencer Kelley et al. (2015) evaluated an automated, interactive audio-recorded storybook
intervention (‘Story Friends’) which was designed to improve vocabulary and comprehension in
4-year-old children from low income families who had low vocabulary and overall language
scores. The participants in the intervention group demonstrated significantly greater improvement
on inferential comprehension of narratives than the waitlist-control group, with no difference for
literal comprehension questions (Spencer Kelley et al., 2015).
Using a single-participant case study design, Spencer et al. (2013) investigated the effect of
individual narrative retelling intervention for five 4-year-old children from low income homes with
significantly delayed language abilities. All participants demonstrated improvements on narrative
retelling, narrative comprehension (five literal and one inferential question), and personal narrative
generation (Spencer et al., 2013).
Only two studies have specifically investigated oral inferential comprehension interventions for
young children with DLD (Desmarais et al., 2013; van Kleeck et al., 2006). Both used dialogic book-
sharing with children aged between 3 to 6 years with DLD, with scripted questions as the intervention
context. Scaffolding and modeling (thinking aloud) were used to support children in responding to
questions. Van Kleeck et al. (2006) provided two individual intervention sessions a week over 8
weeks, with two books read repeatedly. Desmarais et al. (2013) provided one individual intervention
session a week over 10 weeks, with five different books each read for two consecutive sessions.
Van Kleeck et al. (2006) found that the children who received the intervention showed a statisti-
cally significant increase in receptive vocabulary, literal, and inferential comprehension scores (as
measured by the PLAI; Blank et al., 1978b), whereas the control group (who did not receive inter-
vention) showed no change. Similarly, Desmarais et al. (2013) found statistically significant
increases in scores of inferential comprehension of narrative discourse and on the PLAI-II (Blank
et al., 2003). However, the improvements found could not be clearly attributed to the intervention
as the narrative assessments used were not comparable, there was no baseline for the PLAI, and no
control group was used (Desmarais et al., 2013).
These findings provide promise for the use of dialogic book sharing in improving oral inferen-
tial comprehension in young children with DLD. However, both studies identified limitations,
including a lack of treated control groups and blinding, lack of maintenance follow up, poor inter-
nal validity, and non-equivalent assessments.
As such, this study aimed to develop, trial, and evaluate a theoretically informed manualized
small-group intervention targeting oral inferential comprehension within a book sharing context
for 5- to 6-year-old children with DLD to build on these findings, and add to the evidence base. A
randomized controlled trial design was used to target both inferential and literal comprehension
within a discourse context. Both inferential and literal comprehension were measured using a
newly developed assessment. We included a treated control group and blinded post-intervention
assessors, and assessed outcomes at three time points, including maintenance, to address the limi-
tations identified above.
We hypothesized that:

1. Inferential comprehension in children with DLD aged 5 to 6 years would improve signifi-
cantly following an 8-week inferential comprehension intervention compared to a control
group.
2. Improvement in inferential comprehension would be maintained at 8-week follow-up.
Dawes et al. 43

Table 1.  Assessment schedule.

Assessment Assessor Assessments completed

Pre-intervention (T1) Researcher The Squirrel Story Narrative retell and NCA.
PIPA.
Post-intervention (T2) Blinded research The Squirrel Story Narrative retell and NCA.
assistants Peter and the Cat Narrative retell and NCA.
PIPA.
Maintenance (T3) Blinded research The Squirrel Story Narrative retell and NCA.
assistants PIPA.

Notes. NCA = Narrative Comprehension Assessment; PIPA = Primary Inventory of Phonological Awareness.

II Methods
1 Participants
Participants were recruited from pre-primary classes (5 to 6 years of age) in a Language
Development Centre, which provides intensive, language focused early years schooling to children
with DLD in Western Australia. Students must demonstrate a profile of skills consistent with DLD,
including mild to severe expressive and/or receptive language difficulties as measured by standard-
ized assessment, and functional communication difficulties. Referrals to the Language Development
Centre are completed by a speech and language therapist, and include comprehensive case history,
standardized and norm-referenced language assessments, non-verbal IQ assessment or Pediatrician
assessment, and developmental and behavioral checklists.
Parent/carer information letters and consent forms were sent to pre-primary students who the
class teacher identified as having mostly intelligible speech at discourse level within known con-
text (to ensure reliability in transcription and scoring). Thirty-seven children (27 males and 10
females) with consent completed the pre-intervention assessment battery. All of the participants
spoke English as their primary language. Three of the participants were exposed to a language
other than English at home or via extended family (Mandarin, Malay, and Russian). The mean age
of the participants at the pre-intervention assessment was 5;5 (years; months).

2 Procedure
Participants completed assessments at three time points: pre-intervention, immediate post-inter-
vention, and maintenance at 8 to 9 weeks post-intervention (see Table 1). The pre-intervention
assessments were completed by the primary researcher, and the post-intervention and maintenance
assessments were completed by trained research assistants blind to intervention condition.
Participants were randomly allocated to one of two intervention groups (inferential comprehension
or phonological awareness) following the pre-intervention assessment. Participants in both groups
received two, 30-minute small-group intervention sessions a week over 8 weeks with the primary
researcher. This time period was selected to fit within the typical school term, and mapped to the
frequency reported for individual therapy evaluated by van Kleeck et al. (2006).

3 Measures
The Squirrel Story Narrative Comprehension Assessment (NCA) was administered with the Squirrel
Story Narrative retell assessment on iPad (Carey et al., 2006). The Squirrel Story NCA was devel-
oped by the researchers based on research by Paris and Paris (2003) to provide an age-appropriate
44 Child Language Teaching and Therapy 35(1)

measure (Dawes, 2017; Dawes et al., 2018a), and includes 14 inferential and 5 literal questions.
Responses are scored on a scale of 0 to 2, providing a total score out of 28 for inferential, and 10 for
literal comprehension. The Squirrel Story narrative on iPad was administered using the Australian
male voice setting. After hearing the story with the pictures, the child was asked the NCA compre-
hension questions while looking back through the pictures, and responses were audio-recorded on
the iPad app. This assessment was completed at all three assessment points.
The Peter and the Cat Narrative Comprehension Assessment (NCA) (Dawes, 2017; Dawes
et al., 2018b) using the Peter and the Cat Narrative retell assessment on iPad (Leitão and Allan,
2003) was also developed by the researchers based on Paris and Paris (2003). It includes 14 infer-
ential and 6 literal questions, administered and scored in the same way as the Squirrel Story NCA.
The Peter and the Cat NCA was completed post-intervention as a measure of narrative comprehen-
sion generalization.
The Preschool and Primary Inventory of Phonological Awareness (PIPA; Dodd et al., 2000) is a
standardized phonological awareness assessment with Australian norms. It was completed at all
three assessment points.

4 Inter-rater reliability
Ten percent of all literal and inferential scores at each assessment point were randomly selected to
be re-scored by two speech and language therapists who were blind to intervention condition. The
intra-class correlation values for all scores indicated appropriate reliability (> 0.75; range: 0.832–
1.00) (Cicchetti, 1994).

5 Randomization
Participants were randomly allocated to the two intervention groups within each participating pre-
primary class to control for teaching effects. Nineteen participants were allocated to the inferential
comprehension (IC) group and 18 to the control phonological awareness (PA) group. Class teachers
were blind to participants’ intervention group. A series of independent samples t-tests demonstrated
that the IC and PA group mean scores prior to intervention were not significantly different for the
Squirrel Story NCA inferential and literal comprehension scores (t(35) = .867, p = .392 and t(35) =
1.005, p = .322, respectively) or the PIPA average subtest standard scores (t(35) = .041, p = .967).

6 Interventions
a  Inferential comprehension intervention (ICI).  The ICI was designed based on a detailed literature
review (Dawes, 2017), and the results of an earlier study which profiled the language and cognitive
skills contributing to oral inferential comprehension of narratives in 5- to 6-year-old children with
DLD (Dawes et al., 2018c). The profile of skills contributing to inferencing in this population (nar-
rative retelling, literal comprehension, theory of mind, and vocabulary) and the literature review
were used to develop 13 intervention principles which informed the design of the ICI (see Table
2). Examples from the intervention programme are provided in Table 3 (Dawes et al., 2015).
The ICI used four well-known picture books selected due to the quality of their narrative macro-
and micro-structure, ability to infer higher-level emotions, vocabulary, and the perceived engage-
ment of illustrations. The ICI focused on each narrative for four sessions (over two weeks) using
scripted session plans with a repeated sequence of activities (see Tables 4 and 5). Each session was
scripted to include task instructions, models, and questions. The session goals were made explicit
to the participants at the beginning of every session, and the focus on inferential comprehension
Dawes et al. 45

Table 2.  Inferential comprehension intervention principles.

Intervention principle References

1 Ensure that intervention is focused at the discourse-level. Focus Dawes, 2017; Gillam et al., 2012;
on narrative retelling (macrostructure and microstructure) van Dijk and Kintsch, 1983
ability, in addition to literal and inferential narrative
comprehension, to support the development of well-structured
and coherent narrative schemas.
2 Use dialogic book-sharing with scripted literal and inferential Desmarais et al., 2013; van Kleeck,
questions embedded during reading of a text. 2006; van Kleeck et al., 2006
3 Use a range of open-ended inferential comprehension questions Dunst et al., 2012; Paris and Paris,
(causal, informative, evaluative) to promote inferential thinking 2007; Spencer Kelley et al., 2015;
and discussion about narratives. van Kleeck, 2008; van Kleeck et al.,
2006
4 Integrate developmentally appropriate theory of mind skills Dawes, 2017; Westby and
in questioning and discussion, including predicting thoughts, Robinson, 2014
feelings, and behaviours, and linking feelings to prior
experiences.
5 Use think-alouds to model appropriate comprehension Beck and McKeown, 2001;
processes and to prompt children to engage in inferential McClintock et al., 2014; McGee
thinking (e.g. I think…, I wonder…). and Schickedanz, 2007; Paris and
Paris, 2007; van Kleeck, 2008
6 Relate the story and events within the story to children’s Dunst et al., 2012; Spencer Kelley
personal experiences and make predictions. et al., 2015
7 Focus on meta-narrative awareness by explicitly unpacking story Westerveld and Gillon, 2008
grammar elements, discussing what makes a ‘good’ story, and
encouraging children to monitor their own and others’ retelling
of stories in terms of whether all story grammar elements were
included.
8 Use scaffolding techniques to support children to respond to Desmarais et al., 2013; Paris and
inferential comprehension questions, including rephrasing the Paris, 2007; van Kleeck, 2006;
question, providing semantic and phonemic cues, and using cloze Westerveld and Gillon, 2008
sentences.
9 Use graphic organizers, via the use of story grammar elements Dexter and Hughes, 2011; Idol,
and sketches, to create a story map to assist children in 1987; Paris and Paris, 2007;
understanding, remembering, and recalling the story structure. Ukrainetz, 1998; Westerveld and
Gillon, 2008
10 Establish and maintain an explicit focus on inferential Dunning, 1992; Paris and Paris,
comprehension by alerting children to the use of inferencing 2007; van Kleeck, 2006, 2008
skills and making learning goals explicit.
11 Use stories containing well-defined story structure, higher Beck and McKeown, 2007; Dawes,
level vocabulary, and emotions, whilst providing exposure to 2017; Gillam et al., 2012; Spencer
literate language, and embed discussion of higher level (Tier II) Kelley et al., 2015; Westerveld and
vocabulary during book-sharing. Gillon, 2008
12 Ensure that book-sharing is engaging by increasing the salience Dunst et al., 2012; Paris and Paris,
of naturalistic book-sharing strategies (e.g. facial expression, 2007; van Kleeck, 2008
tone of voice, volume, balance of comments and questions, etc).
13 Use of repeated reading of story books. Gillam et al., 2012; Spencer et al.,
2013; Spencer Kelley et al., 2015;
Strouse et al., 2013
46 Child Language Teaching and Therapy 35(1)

Table 3.  Intervention examples.

Principle Example: The Very Brave Bear (Bland, 2013)

3 Inferential comprehension questions: Why did Boris Buffalo jump out of the mud?
How do you think that Bear felt when Boris Buffalo jumped out from the mud?
Why didn’t Bear and Boris go into the cave?
5 Think-alouds: The log looks very wobbly, I wonder if bear will fall off! … I think Bear feels grumpy
because Boris was just as brave as him climbing up the tree!
6 Link to prior experiences and make predictions: have you seen a bear / buffalo before? Where?
When? Where do you think the bear and buffalo live? What do you think might happen in the story?
Have you felt scared before?, what made you feel scared?, why did you feel scared?.
What do you think happens next?
11 Higher level vocabulary: slimy, grin, mighty, pleasant, hurry
Emotions: scared, brave

Table 4. Narratives.

Intervention weeks Narrative

1–2 The Very Brave Bear (Bland, 2013)
3–4 Monkey Puzzle (Donaldson and Scheffler, 2000)
5–6 Giraffes Can’t Dance (Andreae and Parker-Rees, 2000)
7–8 The Gruffalo (Donaldson and Scheffler, 2001)

Table 5.  Intervention sessions outline.

Session Focus
1 Book sharing, shared creation of a story map, retelling part of the story using the story map
2 Book sharing, shared creation of a story map, retelling all of the story using the story map
3 Book sharing, retelling using the story map, discussion about character emotions and linking
emotions to personal experiences
4 Book sharing, retelling using the story map, prediction (after the end of the story)

was made explicit by referring to inferencing as ‘working it out thinking’. The intervention pro-
gramme is freely downloadable (Dawes et al., 2015).

b  Control phonological awareness (PA) intervention. The Gillon Phonological Awareness Training

(PAT) Programme (Gillon, 2008) was selected as the control intervention as it has been shown to be
effective for young children with DLD (Gillon, 2000; Gillon, 2002). The PAT Programme is freely
available (via http://www.canterbury.ac.nz/education/research/phonological-awareness-resources).
Intervention session plans followed the progression of goals in the PAT Programme and were devel-
oped based on the information and examples in the manual. A focus on phoneme segmentation and
blending was maintained throughout the PA intervention.

III Results
The means, standard deviations, and range for the literal and inferential scores from the
Squirrel Story NCA are displayed in Table 6, and for the Peter and the Cat NCA the results
Dawes et al. 47

Table 6.  Means, standard deviations and ranges of the Squirrel Story NCA Scores.

Time Measure Group Mean Standard Range

deviation
Pre-intervention (T1) Inferential comprehension IC 10.84 2.71 6–15
PA 11.65 2.29 8–16
Literal comprehension IC 3.21 1.13 1–5
PA 3.53 1.28 1–5
Post–intervention (T2) Inferential comprehension IC 15.53 3.47 7–20
PA 12.29 2.89 6–17
Literal comprehension IC 4.32 1.53 2–7
PA 4.76 1.39 3–8
Maintenance (T3) Inferential comprehension IC 15.05 2.88 9–22
PA 11.94 3.31 4–17
Literal comprehension IC 4.47 1.02 3–6
PA 4.41 1.06 3–6

Notes. IC = inferential comprehension (IC); PA = phonological awareness (PA).

Table 7.  Means, standard deviations and ranges of Peter and the Cat NCA scores.

Time Measure Group Mean Standard Deviation Range

Post-intervention (T2) Inferential IC 12.16 3.50 9–22
comprehension PA 8.94 2.88 4–15
Literal IC 5.68 1.34 3–8
comprehension PA 5.06 1.35 2–7

Notes. IC = inferential comprehension (IC); PA = phonological awareness (PA).

are displayed in Table 7. Generalized linear mixed models (GLMMs) were used to analyse
the effects of the inferential comprehension intervention at three time points: pre-interven-
tion (T1), post-intervention (T2), and maintenance (T3). The GLMMs included one nominal
random effect (participant), one categorical fixed effect (group: IC versus PA control), one
ordinal fixed effect (time: T1–T3), and the Group × Time interaction. The GLMM ‘robust
statistics’ option controlled for violations of normality and homogeneity of variance.
Violations of sphericity, which were associated with multiple assessments of the same indi-
viduals, were accommodated by changing the covariance matrix to autoregressive. Thirty-
seven participants provided adequate power for an 80% chance of capturing ‘moderate’ (f =
.22) intervention effects at an alpha-level of .05. The reported effect sizes are partial eta
squared (.01 = small; .06 = moderate; .14 = large) and Cohen’s d (.2= small; .5 = medium;
.8 = large).

1 Inferential comprehension
There was an intervention effect for average inferential comprehension scores on the Squirrel Story
NCA, as the Group × Time interaction was significant, F(2,104) = 8.97, partial eta-squared = .079,
p < .001. As such, the main effects for group and time could not be reliably interpreted indepen-
dently of one another. The Group × Time interaction is displayed in Figure 1.
The simple main effects of time were examined separately for each group to investigate the
nature of the interaction. There was a significant effect of time for the IC group, F(2,104) = 19.50,
48 Child Language Teaching and Therapy 35(1)

Figure 1. Group × Time interaction for the Squirrel Story NCA inferential comprehension scores.

partial eta-squared = .157, p < .001, but not for the PA group, F(2,104) = 1.17, partial eta-squared
= .011, p = .315.
Least significant difference contrasts for the IC group showed that there was a significant T1 to
T2 increase in average inferential comprehension scores on the Squirrel Story NCA (t(104) =
5.650, Cohen’s d = 1.883, p < .001), followed by a non-significant T2 to T3 decrease (t(104) =
0.806, Cohen’s d = 0.269, p = .422). The T1–T3 increase was also significant (t(104) = 5.911,
Cohen’s d = 1.970, p < .001), indicating maintenance of inferential comprehension gains.

2 Literal comprehension
The Group × Time interaction for the Squirrel Story NCA literal comprehension scores was non-
significant, indicating that there was not an intervention effect, F(2,104) = 0.78, partial eta-squared
= .007, p = .460. As such, the group and time main effects were interpreted independently of one
another. The group effect was non-significant, F(1,104) = 0.91, partial eta-squared = .009, p =
.342. This indicated that there was no significant difference between the IC and PA groups at any
of the three assessment points. However, the time effect was significant, F(2,104) = 14.12, partial
eta-squared = .120, p < .001. This indicated that both groups changed across time at the same rate.
The main effect for time is displayed in Figure 2.
Least significant difference contrasts showed a significant T1 to T2 increase in literal compre-
hension scores across both groups, t(104) = 4.38, Cohen’s d = 1.460, p < .001. This was followed
by a non-significant T2 to T3 decrease, t(104) = 0.38, Cohen’s d = 0.127, p = .705. The T1 to T3
increase was significant, indicating maintenance of literal comprehension gains for both groups,
t(104) = 4.84, Cohen’s d = 1.613, p < .001.
Dawes et al. 49

Figure 2.  Time effect for the Squirrel Story NCA literal comprehension scores.

a Generalization.  The Peter and the Cat NCA scores at post-intervention (T2) were analysed to
investigate generalization of comprehension gains. The inferential comprehension scores of the IC
group were significantly higher than those of the PA group, F(1,35) = 9.73, partial eta-squared =
.218, p = .004. There was no significant difference between the IC and PA group scores for literal
comprehension, F(1,35) = 2.22, partial eta-squared = .060, p = .145.

b  Reliable change.  The reliable change index (RC) was used as a meaningful measure of signifi-
cant change (Jacobson and Truax, 1991). The RC score was calculated by dividing participant
changes on the outcome variable (inferential comprehension score) by the standard error of differ-
ence between the pre- and post-intervention scores. This reflected the degree to which each partici-
pant’s inferential comprehension score changed. The reliable change criterion was calculated as
4.23 (Devilly, 2004). As the comprehension task was scored in total marks, each participant’s pre-
to post-intervention inferential comprehension score difference for the Squirrel Story NCA was
required to exceed 5 to demonstrate reliable change.
The mean inferential comprehension score change from pre- to post-intervention was higher in
the IC group (M = 4.68) than the PA group (M = 0.83). A Pearson’s chi-square test of contingen-
cies was significant, χ² (1, n = 37) = 11.56, p = .001, with a large effect ɸ = .56. This demon-
strated that the proportion of participants showing reliable inferential comprehension score
improvement was significantly higher in IC group (57.9%) than in the control PA group (5.6%).

IV Discussion
Inferential comprehension is important for both everyday conversation and more literate language
such as reading comprehension. There is limited evidence of the effectiveness of interventions for
oral inferential comprehension, particularly for young children with DLD. The findings of this
50 Child Language Teaching and Therapy 35(1)

randomized controlled trial provide support for the effectiveness of the small-group inferential
comprehension intervention for 5- to 6-year-old children with DLD. In addition to the group level
findings, the use of the reliable change index demonstrated meaningful gains at the individual
level. Improvements were shown to generalize to a different measure (Peter and the Cat NCA), and
were maintained 8 to 9 weeks following the intervention.
As a randomized controlled trial, this study was able to address some of the limitations identi-
fied by van Kleeck et al. (2006) and Desmarais et al. (2013). The use of a consistent measure (the
Squirrel Story NCA) ensured that an equivalent assessment was used to measure change, address-
ing the limitation identified by Desmarais et al. (2013). While using the same measure can be a
limitation, the use of an additional post-intervention assessment (Peter and the Cat NCA) provided
stronger support for the observed changes being attributable to the intervention. The inclusion of a
treated control group, blinded research assistants for post-intervention and maintenance assess-
ments, blinded teachers and randomization within classrooms to control for teaching effects, a
maintenance assessment, and a larger sample size also strengthen this study’s findings.
The IC participants demonstrated the most improvement on inferential comprehension ques-
tions requiring causal reasoning (including inferring emotions), prediction, and evaluative reason-
ing. These skills were explicitly targeted during intervention sessions (see intervention principles
3, 4, 6, and 10, Table 2). The repeated exposure to, modeling, and practice of, narrative comprehen-
sion and retelling during the intervention was hypothesized to support the development of organ-
ized, robust narrative schema. This, in turn, was predicted to support efficient and effective
processing, comprehension, and recall of narratives and, subsequently the drawing of inferences
(Bishop, 2014; van Dijk and Kintsch, 1983). The findings of this study, including the generaliza-
tion of inferential comprehension gains across the narrative context, support this hypothesis.
It should be noted that the intervention was not effective for all participants, with three show-
ing little or no change. While the pre-intervention profiles of these students were similar to those
of other participants, they demonstrated poor listening and attention during the sessions, which
may have impacted their ability to access the intervention. As such, it would be useful for future
research to consider listening and attention skills when planning intervention and to investigate
response to individual intervention for these children, including factors which may impact their
response to the intervention.
It is acknowledged that the Narrative Comprehension Assessments were developed for this
study. However, there are few standardized assessments which specifically assess oral inferential
comprehension, and those available present limitations for the age and population of this study.
The NCAs were piloted on typically developing children prior to the research, and inter-rater reli-
ability was completed to ensure that scoring met reliability standards. It would be useful for future
research to include measures of treatment fidelity, a more general measure of comprehension
which is reflective of everyday contexts (e.g. the PLAI), longer-term follow up (e.g. 12 months or
more), and measures to investigate underlying mechanisms of change (such as theory of mind,
vocabulary, and listening and attention).
While the focus of this intervention was inferential comprehension, literal comprehension was an
intrinsic component and was also measured. The results indicated that the inferential comprehension
intervention was not effective at improving the literal comprehension of participants in the IC group,
which supports the notion that literal and inferential comprehension are related but distinct skills
(Oakhill, 1984; Potocki et al., 2013). This finding may reflect that different skills underpin literal
and inferential comprehension, as effective inferential comprehension is hypothesized to be more
reliant on robust schematic structures (van Dijk and Kintsch, 1983), whereas literal comprehension
is thought to be more reliant on memory recall (Potocki et al., 2013). This finding has clinical impli-
cations, as literal and inferential comprehension should be considered as independent (but related)
Dawes et al. 51

skills in both assessment and intervention (i.e. assessment should yield separate scores for literal and
inferential comprehension rather than one total score, and interventions should address both).
Interestingly, participants in both the IC and PA groups demonstrated significant improvement
in literal comprehension from pre- to post-intervention. This finding may suggest that the ongoing
classroom programmes at the Language Development Centre and/or developmental improvement
positively influenced literal comprehension. It is also pertinent to note that the NCAs included a
relatively small number of literal questions, and therefore may not have provided sufficient scope
to demonstrate a difference between the two intervention groups. Future research should investi-
gate targeting literal comprehension more directly, and including additional literal comprehension
questions in assessment.

V Conclusions and clinical implications

This study was a randomized controlled trial which targeted oral inferential comprehension of nar-
ratives in a group of 5- to 6-year-old children with developmental language disorder using a theo-
retically-motivated small-group intervention in the context of book sharing. The results
demonstrated that the intervention was effective at improving inferential comprehension of narra-
tives, that improvement generalized across narratives, and that improvement was maintained over
time. These findings contribute to the clinical evidence base of interventions focusing on language
comprehension in children with DLD and, in particular, provide clinicians with stronger evidence
that inferential comprehension of narrative discourse can be improved in young children with
DLD. The assessments developed for this study and the full intervention are available for clinicians
to access freely online (Dawes et al., 2015, 2018a, 2018b).

Declaration of Conflicting Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publi-
cation of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publica-
tion of this article: This study was conducted as part of doctoral research by Emily Dawes at Curtin University.
The authors would like to acknowledge the support of Curtin University and an Australian Government
Research Training Program Scholarship in completing this research. Thank you to the Language Development
Centers and participants involved in this study.

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