School Mental Health (2014) 6:251–263

DOI 10.1007/s12310-014-9127-7

ORIGINAL PAPER

A Story Mapping Intervention to Improve Narrative

Comprehension Deficits in Adolescents with ADHD
Karen J. Derefinko • Angela Hayden •
Margaret H. Sibley • Jake Duvall • Richard Milich •

Elizabeth P. Lorch

Published online: 20 May 2014

Ó Springer Science+Business Media New York 2014

Abstract The current study examined the effects of an Introduction

8-week story mapping intervention (SMI) to improve nar-
rative comprehension in adolescents with attention-deficit Attention-deficit hyperactivity disorder (ADHD) is one of the
hyperactivity disorder (ADHD). Thirty 12–16-year-old most commonly diagnosed childhood behavioral disorders
adolescents with ADHD who were participating in a with prevalence rates as high as 10 % (Barkley, 2006). It is
summer treatment program for adolescents with ADHD well documented that children with ADHD have academic
received the SMI instruction ten times and completed SMI difficulties and that these difficulties are compounded over
homework ten times in a structured environment with time (Barbaresi, Katusic, Colligan, Weaver, & Jacobsen,
teacher feedback. Recall of fables and story creation were 2007; Kent et al., 2011; Loe & Feldman, 2007). In middle
assessed before and after the SMI. At post-test, fable school, individuals with ADHD experience substantially more
recalls included more of the most important events, were academic impairment than their peers (Molina et al., 2009;
more coherent, and included a greater number of plausible Schultz, Evans, & Serpell, 2009), and by high school, students
inferences than pre-test fable recalls. SMI homework with ADHD display lower grade point averages (GPAs), are
scores accounted for increases in recall of important events placed in more remedial classes, are more likely to fail classes,
and plausible inferences, suggesting that consistent practice and are more likely to drop out of school (Barkley, Fischer,
and feedback with story mapping could contribute to Smallish, & Fletcher, 2006; Kent et al., 2011). These findings
important recall gains. In contrast, the inclusion of goal- are consistent with those found in other longitudinal studies
based events and the rated coherence of created stories did that report grim academic outcomes for secondary school
not improve, suggesting that more explicit instruction in students with ADHD (Barbaresi et al., 2007; Barkley et al.,
applying story mapping to story creation may be required. 2006), and these problems are likely contributors to employ-
ment issues that arise later in adulthood (Kuriyan et al., 2013).
Keywords ADHD
Adolescence
Story recall
Because these academic problems do not appear to self-cor-
Comprehension
Story map rect overtime and have long-term consequences, intervention
for specific academic deficits could be of tremendous benefit
for adolescents with ADHD.
Children and adolescents with ADHD exhibit a broad
range of academic difficulties, but a notable problem area is
narrative comprehension (Flory et al., 2006; Lorch, Ber-
thiaume, Milich, & van den Broek, 2007). Narrative com-
K. J. Derefinko (&)
A. Hayden
J. Duvall
R. Milich
prehension represents a skill set believed to underlie broad
E. P. Lorch academic functioning relevant to later academic progress,
University of Kentucky, Lexington, KY, USA above and beyond other traditional indicators such as word
e-mail: kjdere2@uky.edu
identification, semantic, and syntactic skills (Feagans &
M. H. Sibley Applebaum, 1986; Kendeou et al., 2005). Major theories of
Florida International University, Miami, FL, USA narrative comprehension point to skills needed to construct

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a coherent story representation. For example, story gram- Lorch & Milich, 2007). Unfortunately, these deficits are
mar theory (Mandler & Johnson, 1977; Stein & Glenn, not eliminated with development (Lorch, Milich, Flake,
1979) defines categories of story events according to the Ohlendorf, & Little, 2010) and may last into adulthood.
major role of each event in the story. Of particular impor- Finally, effective narrative comprehension requires the
tance from this point of view are a principal character’s generation of reasonable inferences. Goals and causal
goals (G), attempts to achieve goals (A), and outcomes of connections between events often are not explicitly stated
these attempts (O). Linking goals, attempts, and outcomes in stories, but must be inferred from story events (Thurlow
into GAO sequences are critical to building a coherent & van den Broek, 1997). Although inference generation
representation of story events, whether the task is to recall, among adolescents with ADHD has not been studied
narrate, or create a story. The causal network model extensively, recent work suggests that children with ADHD
(Trabasso & van den Broek, 1985; Trabasso, van den produce fewer inferences that plausibly explain story
Broek, & Suh, 1989) incorporates story grammar theory’s events but produce more implausible or erroneous infer-
definition of events but also stresses the causal connections ences (Berthiaume, Lorch, & Milich, 2010). These findings
that link antecedent and consequent events. Understanding suggest that youth with ADHD struggle to make implicit
causal connections between story events is critical to cre- connections among story events that are vital to the con-
ating an organized representation of a story and in guiding struction of a complete and coherent story representation.
recall of important events. Development of skills in the
construction of coherent story representations provides a Intervention Strategies
basis for later comprehension of more complex information
and organized writing skills (Low & Durkin, 1998), both Given the documented deficits in narrative comprehension,
undoubtedly necessary for secondary school success. it is important to develop intervention strategies to remedy
Youth with ADHD exhibit several related, but distinct such deficits for individuals with ADHD. However, much
deficits in skills implied by these narrative comprehension research to date has failed to yield promising results in
models, including (1) difficulty making causal connections addressing a variety of academic difficulties. Given the
among story events, (2) difficulty using goal structure to frequency with which it is prescribed, the treatment effi-
create a coherent story, (3) difficulty identifying important cacy of stimulant medication in particular has been
events to guide recall, and (4) difficulty generating infer- investigated extensively in youth with ADHD (Barkley,
ences (Lorch et al., 2007). Importantly, youth with ADHD 2006; Loe & Feldman, 2007). Although many treatment
often do not differ from comparison peers when recalling studies have suggested that stimulant medication is suc-
discrete, factual story events, but consistently perform cessful in improving basic academic functioning, such as
more poorly than comparison peers when answering reducing disruptive behavior, increasing homework com-
questions testing understanding of causal relations (i.e., pletion, and improving quiz grades (Evans et al., 2001;
‘‘why’’ questions; Lorch et al., 1999, 2000, 2004). Relat- Pelham et al., 2013), longitudinal research has shown that
edly, youth with ADHD have shown specific deficits in such treatment does not improve academic performance in
incorporating and maintaining a goal plan across a variety the long term (Barkley, 2006; Langberg & Becker, 2012).
of storytelling procedures including telling a story (with Three studies have examined the effects of stimulant
and without prompts), narrating a wordless picture book, medication on narrative comprehension and production.
and recalling a story that they have previously heard or Two focused on the effects of stimulant medication on story
read (Derefinko, Bailey, Lorch, Milich, & Riley, 2009; recall. Francis, Fine, and Tannock (2001) asked 50 children
Flory et al., 2006; Renz et al., 2003). Difficulties under- with ADHD to retell stories from memory both on and off
standing causal connections and maintaining goal plans stimulant medication. Although children showed some
suggest that youth with ADHD construct less coherent improvement in including the story grammar categories of
story representations whether creating or recalling a story. story characters’ internal responses and attempts, stimulants
Perhaps due to deficits in understanding causal con- did not improve overall story recall length or accuracy of
nections and goal structure, youth with ADHD also dem- responses to comprehension questions. In another study of
onstrate problems in identifying important information the effects of stimulant medication on free recall of children
within a narrative. Given that goals and events with many with ADHD (Bailey, Derefinko, Milich, Lorch, & Metze,
causal connections are likely to be important to a narrative 2011), stimulant medication was associated with increases in
(Trabasso & Sperry, 1985), it is not surprising that youth the number of events recalled, but had no significant effect on
with ADHD are less sensitive to the importance of infor- recall of events central to the stories or on the coherence of
mation than comparison peers. When recalling stories, recalls. A third study (Derefinko et al., 2009) minimized
recall generally increases as event importance increases, memory demands by investigating the effects of stimulant
but this effect is smaller for individuals with ADHD (Flake, medication on the inclusion of goal-based story events as

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children narrated wordless picture books. Children produced narratives using a specific structure (Boulineau, Fore, Ha-
a larger number of clauses in the medication condition than gan-Burke, & Burke, 2004). The map provides readers with a
in the placebo condition, but there was no significant effect of space to record important story grammar categories includ-
medication on the inclusion of goal-based story events. ing: setting, characters, problem, goals, actions, outcome,
Taken together, these studies indicate that stimulant medi- and conclusion of the story. The purpose of instruction with a
cation leads to little improvement in complex narrative story map is to improve narrative comprehension by helping
comprehension and production. students to understand the structure of a coherent story rep-
A second general approach often employed to improve resentation, with emphasis on the causal connections
academic performance for children and adolescents with between characters’ goals, their attempts to achieve goals,
ADHD is instruction on improving organization of ideas and the outcomes of those attempts (Boulineau et al., 2004).
through strategic studying, note-taking, and essay construc- As mentioned, story maps have been effective for strug-
tion. Children with ADHD have difficulty organizing ideas gling readers in both single-technique intervention studies
into a coherent representation without instruction, even when focusing on story mapping, as well as studies examining the
given time to study and common study aids to help them (i.e., a combined effects of multiple techniques. In two studies that
highlighter, a piece of paper and a pen, Lorch et al., 2004). examined the effect of interventions focusing on story map-
Approaches that do provide these children with instruction on ping, Idol and Croll (1987) and Boulineau et al. (2004)
organizing information into a coherent representation are not explicitly instructed struggling readers on story grammar
necessarily effective at addressing the deficits specific to categories and story structure using story maps. Students in
comprehension in youth with ADHD. Children who were both studies received extensive feedback from teachers on
instructed on the directed note-taking activity (DNA) proce- correct identification of story grammar elements through story
dure by Evans, Pelham, and Grudberg (1995) learned how map completion. Participants in Idol and Croll (1987) showed
notes should be organized using a format that stressed main improved comprehension, and most maintained comprehen-
ideas. Although adolescents were able to record over 80 % of sion gains when story maps were removed. Students in Boli-
details from a lecture with the DNA instruction, they did not neau et al. (2004) improved in the identification of story
improve in identifying main ideas. One organizational tech- grammar elements from pre-test to post-test, and accuracy of
nique that has been utilized successfully to address deficits identification was maintained after removal of instruction.
associated with organizing thoughts into coherent writing is a These studies suggest that interventions that focus on story
technique described as self-regulated strategy development mapping as a technique may effectively improve compre-
(SRSD; Harris & Graham, 1996). SRSD utilizes ‘‘instruc- hension. DuPaul et al. (2006) and Jitendra et al. (2007) utilized
tional strategies’’ to addresses three deficits that may con- a story mapping technique as one available component among
tribute to writing issues with ADHD, including goal-setting multiple components of a reading intervention package in
issues, poor self-regulation, and working memory deficits. large-scale, long-term, academic intervention studies for
Children and adolescents with ADHD have shown improve- children with ADHD. Both studies found evidence of
ment with this procedure (e.g., Jacobsen & Reid, 2010; De La improved comprehension for these struggling readers,
Paz, 2001). However, few studies have examined the use of although the unique contribution of story mapping instruction
SRSD as a stand-alone strategy to improve writing in indi- cannot be determined. As a whole, these studies suggest that
viduals with ADHD. instruction in the use of story maps is a promising technique
for improving knowledge of story structure and potentially of
Story Maps as a Potential Intervention narrative comprehension and production.

It appears that common treatment methods such as stimulant

medication, practicing traditional study skills, and broad Current Study
organizational strategies do not address the narrative com-
prehension deficits identified in youth with ADHD. How- Although improvements among children with learning dis-
ever, these treatments were not designed to address these abilities as a function of instruction in use of story maps are
specific deficits. One treatment method, instruction in using promising, and story maps have been utilized as one compo-
the ‘‘story map’’ to guide the construction of a story repre- nent of multifaceted intervention packages for children with
sentation, has been used successfully to address compre- ADHD (DuPaul et al., 2006), use of the story map in
hension deficits in single-case design studies, as well as instruction to address narrative comprehension deficits has yet
serving as a component of larger-scale interventions with to be tested as a specific intervention in individuals with
youth with ADHD (DuPaul et al., 2006; Jitendra et al., 2007). ADHD. The current study investigated the use of a story
Story maps are visual-spatial displays that can be used during mapping intervention (SMI) to improve the narrative recall
instruction to guide attention to important components of and production of adolescents with ADHD. Utilizing a pre–

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post test research design, we sought to explore whether the use Table 1 Demographic information
of the SMI would improve areas of comprehension previously Variable Mean SD Range Percent
shown to be deficient in youth with ADHD, including using
goal structure to create or recall important events, generating Age 13.79 1.33 11.9–16.8
or recalling coherent stories, and generating plausible infer- WASI Full Scale IQ 105.41 11.53 78–133
ences based upon story events. The SMI was designed to target WIAT math 102.90 14.98 65–125
the skills thought to underlie effective narrative comprehen- WIAT reading 104.03 13.01 75–127
sion and the construction of a coherent story representation, WIAT spelling 103.46 14.90 70–133
including attention to characters’ goals and the causal con- DBD ADHD inattentive 7.62 2.19 2–10
nections linking goals, attempts, and outcomes. This inter- symptoms
vention was implemented in a group setting ten times over the DBD ADHD hyperactive 5.17 2.62 0–10
symptoms
course of an 8-week summer program. Both before and after
DBD ODD symptoms 3.96 2.81 0–9
the SMI intervention, recall of audiotaped fables and adoles-
DBD CD symptoms .72 .88 0–3
cents’ independent creation of novel stories was assessed.
Given the focus of the SMI on the goal structure of stories and Single parent household 21.4
the connections among important events, we evaluated whe- History of special services in 33.3
school
ther adolescents with ADHD would show post-test improve-
Race
ment in recalling important events from the fable, in the global
Caucasian 61.9
coherence of the fable recall, and in generation of two types of
Black 4.8
plausible inferences based upon story events. Similarly, for
Asian 4.8
story creation, we examined whether adolescents would show
Ethnicity
post-test improvement in the length of stories created, in the
Latina/o 50.0
inclusion of goal-based story grammar events, and in the
global coherence of stories created. Assuming that extensive History of stimulant 38.1
medication use
practice in story mapping would be important (Boulineau
Current stimulant medication 35.7
et al., 2004; DuPaul et al., 2006; Idol & Croll, 1987), we use
evaluated whether story map homework completion would
N = 30. WASI Wechsler Abbreviated Scale of Intelligence, WIAT
account for any improvements.
Wechsler Individual Achievement Test 3rd edition, DBD Disruptive
Behavior Disorder Rating Scale, ADHD attention-deficit hyperactiv-
ity disorder, ODD oppositional defiant disorder, CD conduct disorder
Method

Participants Parents and teachers of adolescents completed an appli-

cation that contained behavioral rating scales, a demographic
Participants were 30 adolescents with ADHD between the ages questionnaire, and a treatment history form. Parents also
of 12 and 16 years. The adolescents participated in the Sum- were administered the Disruptive Behavior Disorders
mer Treatment Program-Adolescent (STP-A) at a large uni- Interview (DBD; Pelham, Evans, Gnagy, & Greenslade
versity clinic. Participants were required to (a) meet DSM-IV- 1992a), a semistructured interview with supplemental
TR (APA, 2000) diagnostic criteria for ADHD, (b) be at least probes for symptom severity and situational variability.
12 years of age, (c) have a Verbal IQ higher than 80, and Through dual clinician review, participants were accepted to
(d) have no conditions that precluded full participation in the the STP-A if parent and teacher reports indicated the pre-
STP-A activities. Demographic information is included in sence of clinically significant symptoms (assessed by the
Table 1. The STP-A is an intensive behavioral day treatment Disruptive Behavior Disorder Rating Scale; Pelham, Gnagy,
program for adolescents with ADHD that includes an active Greenslade, & Milich 1992b) and cross-situational impair-
parent involvement component (Sibley et al. 2011; Smith et al., ment (assessed by Impairment Rating Scale; Fabiano et al.,
1998). During the STP-A, adolescents receive over 300 h of 2006) consistent with a diagnosis of ADHD. Adolescents
treatment focused on improving skills in academic, social, and were administered the Wechsler Abbreviated Scale of
family domains. In addition, parents participate in 15 h of Intelligence (WASI; Weschler, 1999) to obtain an estimated
behavior management training, 8 weeks of daily practice IQ score and the Word Reading, Spelling, and Mathematics
implementing a home behavioral contract, and ongoing daily subtests of the Wechsler Individual Achievement Test-II
support from a trained clinician. The STP-A shows evidence of (Wechsler, 2002) to assess achievement. Adolescents were
improving the social behavior and academic functioning of excluded from the program if they qualified for a diagnosis of
adolescents with ADHD (Sibley et al., 2011, 2012). pervasive developmental disorder, or a psychotic disorder.

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Parents signed informed consent, and adolescents signed (Pelham et al., 2012). Adolescents attended the program from
youth assent forms prior to treatment. 8:00 am to 5:00 pm each day and participated in modules
designed to mimic a secondary school setting. The STP-A
Materials teaches academic and organizational skills that are relevant to
secondary school (i.e., note-taking, study skills, writing skills,
Fables daily planner use, and binder organization) to foster general-
ization of therapeutic gains. STP-A modules also include daily
One fable, The Knight and the Dragon, was read to the jobs, substance use prevention (i.e., Life Skills Training,
adolescents and recalled during the pre-test, and a second Botvin, 2004), and leadership training to teach life skills and
fable, Silly Richard, was read to the adolescents and prevent maladaptive outcomes such as deviant peer affiliation,
recalled during the post-test. The two fables had been used substance use, and delinquency. The STP-A behavioral
in previous studies for which each fable had been parsed by feedback system is sensitive to adolescent social norms.
trained coders into individual story events. Initial agree- Because ADHD is a heterogeneous disorder, individualized
ment between the coders regarding division of units was treatment plans and adjunct treatments are used as needed to
94 %; disagreements were revised by consensus to deter- customize treatment to the unique deficits of each participant.
mine the final set of events. Thirty-four adults then rated Adolescents were in groups of 9 to 11 similar age peers, and
the importance of events from each fable using a seven- each group was staffed by a graduate student counselor and
point Likert scale ranging from 1 (not important to the three undergraduate counselors. To promote treatment fidel-
overall meaning of the story) to 7 (extremely important to ity, staff members received 60 h of pre-service training and
the overall meaning of the story, Flake et al., 2007). The were required to pass a STP-A procedural test. Staff were
average ratings were converted to quartiles for each fable, supervised by PhD-level mental health professionals and
constituting four levels of importance of events. Both trained fidelity observers. Supervisors and fidelity observers
fables include a main character who has multiple failed completed standardized dichotomous fidelity checklists and
attempts at trying to reach a goal before actually achieving provided daily feedback about adherence to manualized pro-
the goal. Silly Richard is 618 words long and contains 84 cedures. Across treatment fidelity checklists, average fidelity
story events. This story concerns a young boy who wants to scores were above 90 %. Staff were also required to complete
buy a skateboard. His mother tells him that he has to earn weekly treatment fidelity quizzes on STP-A procedures. If any
the money. Richard goes through a number of failed score on a treatment fidelity checklist or weekly quiz was
attempts before earning enough money. The Knight and the below 100 %, it was immediately addressed with remedial
Dragon contains 640 words and contains 85 story events. procedures.
This story is about a king who asks a knight to protect his
people from a dragon that lives on a mountain. The knight Pre-test/Post-test
encounters obstacles on his way to the dragon’s cave, but
the problem is resolved when the dragon later helps the Adolescents completed pre-test measures on the first day of the
knight and accompanies him to the kingdom. program before any instruction occurred, and post-test mea-
sures on the final day at the beginning of the writing class. Pre-
Story Map and post-test measures consisted of a fable recall task and a
story creation task. During both the pre-test and post-test ses-
The story map was used as a concrete organizational aid sions, all adolescents listened to the same fable (pre-test was
during instruction and helped to focus adolescents on impor- The Knight and the Dragon and post-test was Silly Richard)
tant story grammar categories with a particular emphasis on and were instructed to write down what they remembered from
goal structure. Blank spaces of the story map included title, beginning to end after the fable was read. For the story creation
setting, characters, outcome, and vocabulary. Of particular task, adolescents were instructed to make up a story that they
importance during instruction were the blank spaces for goal had never heard before within a 15-min time limit. They were
structure elements, including the major goal, problem, sub- also instructed to write ‘‘The End’’ when finished. If the ado-
goals, attempts, and outcomes (see ‘‘Appendix’’). lescent did not have any information written down within the
first minute, the teacher would advise the adolescent to write
Procedure down whatever they had thought up.

All procedures were approved by the university Institutional Intervention

Review Board. The STP-A is an 8-week intensive summer
treatment program for adolescents with ADHD. The program The story mapping intervention (SMI) took place during the
is fully described in a manual available from the authors writing class in the academic portion of the STP-A. The

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SMI was explained to adolescents at the beginning of the Coding

course by the writing teacher. The writing teacher was a
recruited from the local school system based upon experi- Both fable recall and story creation assessments were
ence in a mental health-related area. She was supervised by transcribed verbatim from the hand written papers of the
a PhD-level mental health professional who attended every adolescents by a coder blind to the testing condition.
class period, completed standardized dichotomous fidelity
checklists, and provided daily feedback about adherence to Fable Recall
manualized procedures. Fidelity to the story mapping
intervention averaged over 95 %, and on the rare occasion Fable recall protocols were parsed into individual events in a
that the teacher did not complete instruction on an aspect of manner similar to that described for the complete fables (see
the story map, the supervisor brought this to her attention above). The events in adolescents’ recalls were compared
immediately so that treatment integrity was maintained. with the actual events in the story (determined as described in
In the first class, the teacher began by asking adolescents the Materials section above). Each actual event was scored 0
to identify elements of a good story (e.g., organization, (not recalled) or 1 (recalled). The percentage recalled for
setting, characters, and plot) and then introduced the story events at each level of importance was calculated. Next, the
map. The teacher asked the adolescents to suggest defini- global coherence of fable recall was rated by trained coders
tions for each concept on the story map, with corrections on a scale of 1 to 4. Global coherence represents the general
made as necessary. The teacher then guided the adolescents logical flow of the entire recall as perceived by adult eval-
in filling in the story map and using the story map to uators (Habermas & de Silveira, 2008) and as such is related
organize a summary of events, using the Introduction to the to how a teacher might grade an essay. A scoring rubric was
collection of stories that served as the material for the class. derived from Habermas and Silveira (2008), and inter-rater
On later days, the teacher continued to guide the students in reliability has been consistently high for previous studies
filling in story maps and correcting those they had com- employing this coding system (Flake et al., 2007; Freer,
pleted as homework (see below). During this instruction, Hayden, Lorch, & Milich, 2011; Lorch et al., 2010). A score
the teacher emphasized identification of the central char- of ‘‘1’’ indicated that the recall had no clear story line, had
acter’s goals, the attempts motivated by those goals, and many gaps, had many flaws and ambiguities, or had no
outcomes that followed from the attempts. transitions. A score of ‘‘2’’ indicated that the recall had some
Story map homework was assigned during every other story line, but poor transitions and many ambiguities. A score
writing class (10 total homework assignments). Time to of ‘‘3’’ indicated that the recall had a story line, few ambi-
complete homework was provided during camp hours under guities, and good transitions. A score of ‘‘4’’ indicated that
counselor supervision in a study hall to increase task the recall had a good story line, almost no ambiguities, and
adherence and concentration. The homework required ado- varied transitions. Finally, fable recalls were coded for two
lescents to read a designated chapter from the book ADHD types of inferences: Explanatory and elaborative. Explana-
and Me: What I Learned from Lighting Fires at the Dinner tory inferences are essential for narrative comprehension
Table (Taylor, 2007), followed by the completion of a story because they fill in causal connections between events and
map. Homework was turned in during the next writing class. outcomes that have not been explicitly stated within the
Students who completed an entire story map accurately story. An elaborative inference adds information to the story
received a grade of ‘‘1,’’ those who attempted the story map, line, but is not essential for narrative comprehension. Both
but did not complete at least 50 % of it (or completed a types of inferences were coded for plausibility (i.e., an
section of it incorrectly) received a grade of ‘‘1/2,’’ and those inference reasonably consistent, given the explicit story
who did not make an attempt to complete the story map or did events). Because implausible inferences were rare, only
not turn in the story map received a grade of ‘‘0.’’ The plausible inferences were utilized in the current study. To
homework scores ranged from a minimum of 36 % to a estimate the inter-rater reliability, two coders coded all of the
maximum of 100 %. Homework was graded while the ado- stories for inferences and 25 % of the stories for recall of
lescents worked on an in-class assignment, and was returned events and coherence. The inter-rater reliability for event
immediately. The teacher then lead the class in a discussion coding was K = .82 at the level of individual events, r = .85
of the assigned chapter by utilizing a blank story map on the for global coherence ratings, and r = .92 for total number of
overhead projector. This discussion served as feedback on inferences.
the adolescents’ story maps as well as additional instruction
in story mapping and its relation to goal structure. During the Story Creation Task
discussion, adolescents corrected their graded story mapping
homework at their desk. Homework scores were averaged The stories adolescents created were parsed into individual
and used as a covariate in analyses. events, in a similar manner to that described for recall

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protocols. Story length was assessed via the number of

events. Events then were coded for whether they fell into
goal-based or nongoal-based categories.
Goal-based categories included categories that are part of
what Stein and Glenn (1979) described as the story’s ‘‘epi-
sode system’’: goal-initiating events, goals, attempts, and
outcomes. Goal-initiating events were events that motivated
a character’s goal. Goals were coded as explicit statements of
what the main character was trying to complete or attain.
Attempts were events where the main character was making
an effort to achieve goals. Outcomes were explanations of
whether the attempt succeeded or failed.
Nongoal-based categories included settings, main char-
acters, characters’ internal responses, and nongoal-related
events (Stein & Glenn, 1979). The setting consisted of Fig. 1 Fable recall as a function of event importance
background information in the study, events such as time and
place. The main character was coded as the protagonist if he seen in Fig. 1, adolescents recalled more events at post-test
or she caused the actions to occur in a story. An internal than at pre-test, F(1, 24) = 29.54, p \ .001, d = 2.22, and
response was an emotional reaction from the main character. overall, more important events were recalled more often, F(3,
Nongoal-based events were actions that took place to move a 72) = 56.03, p \ .001, d = 1.72. These main effects were
story along but were not related to goal sequences. qualified by a significant test 9 importance interaction, F(3,
Global coherence of the stories created was coded with 24) = 29.93, p \ .001, indicating that the slope of the func-
the same 1 to 4 scale that was used for the fable recall. In tion relating recall to importance was steeper at post-test than
order to estimate inter-rater reliability, two coders coded all at pre-test, F(1, 24) = 29.93, p \ .001. Notably, adolescents
of the stories for coherence and 25 % of the stories for recalled only 21.52 % of the most important events at pre-test,
story grammar categories. The inter-rater reliability for but 41.72 % during the post-test.
story coherence ratings was r = .70. Inter-rater reliability When story map homework scores were included in
was [.80 for all story grammar categories, including those these analyses as a covariate, this accounted for significant
related to goal structure. variance in test (pre, post), F(1, 23) = 6.92, p \ .05, and in
the test 9 importance interaction, F(1, 23) = 10.49,
Planned Analyses p \ .01. In addition, when homework scores were con-
trolled for, the main effect of test (pre, post) and the
Pre–post test designs were conducted to explore whether test 9 importance interaction was no longer significant
performance improved as a result of the SMI. For com- (F(1, 23) = .61, ns, and F(1, 23) = 1.55, ns, respectively).
parisons that utilized additional variables (e.g., importance This suggests that the higher the quality of homework, the
of events during recall), ANOVAs were used. In all other greater the effect of the SMI.
instances, planned paired-samples t tests were conducted.
To explore whether improvement was a result of prac- Global Coherence
tice in the SMI intervention, SMI homework scores were
used as a covariate in analyses, and interaction terms were To examine the effects of the SMI on global coherence of
interpreted accordingly. recall, a paired-samples t test compared rated coherence at
the pre-test and the post-test. Recall was significantly more
coherent during the post-test, M = 2.80, than the pre-test,
Results M = 2.04, t(24) = 3.37, p \ .01, d = 1.37, but homework
score was not a significant covariate, F(1, 23) = .38, ns.
Effects of SMI on Fable Recall
Inferences
Recall as a Function of Importance of Events
To examine the effects of the SMI on the generation of
To examine the effects of the story mapping intervention explanatory and elaborative inferences, paired-samples
(SMI) on recall of events as a function of importance ratings, a t tests were used to compare the number of these inferences
2 (Tests: pre-test, post-test) 9 4 (Importance: 4 levels of rated generated at the pre-test and the post-test (see Fig. 2).
importance) repeated-measures ANOVA was conducted. As Adolescents generated more explanatory inferences during

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greater number of nongoal-based events in their stories

during the post-test, t(22) = 5.26, p \ .001, and a greater
number of settings in their stories during the post-test,
t(22) = 2.64, p \ .02, but there were no significant increa-
ses in main characters or internal responses, ps [ .10.

Global Coherence

Raters scored the global coherence of stories created with

the same 1–4 scale previously used for the coherence of
fable recall. A paired-samples t test (pre-test, post-test)
indicated that rated coherence did not significantly improve
between pre-test and post-test sessions, t(22) = .30, ns.
During the pre-test, coherence ratings averaged 2.91,
whereas ratings averaged 2.98 during the post-test.

Fig. 2 Fable recall: mean values of inferences made

Discussion

the post-test, M = 2.81, than during the pre-test, The current study represents preliminary work in the use of
M = 1.81, t(23) = 2.61, p \ .05, d = 1.07. When home- a story mapping intervention (SMI) to improve specific
work scores were controlled for, the covariate effect was narrative comprehension skills in adolescents with ADHD.
significant, F(1, 22) = 4.95, p \ .05, and the effect of the Within the context of a broader clinic-based program,
test was no longer significant, F(1, 22) = 1.89, ns, indi- adolescents received ten sessions of the SMI and com-
cating that improvement in explanatory inferences is pleted associated homework assignments. Pre–post test
accounted for by accurate homework completion. Adoles- comparisons utilizing a fable recall and a story creation
cents also made a greater number of elaborative inferences task were made to examine whether adolescents with
during the post-test, M = 2.83, than during the pre-test, ADHD improved on recall of important events, global
M = 1.33, t(23) = 3.85, p \ .01, d = 1.57, but homework coherence of recall, generation of inferences during recall,
score was not a significant covariate, F(1, 22) = 1.02, ns. story creation events, goal and nongoal-based categories of
story creation, and global coherence of story creation after
Effects of SMI on Story Creation repeated instruction and practice with the use of a story
map.
Events Results indicated significant improvement in a number
of narrative comprehension skills during the fable recall
A paired-samples t test was conducted to examine the task. Specifically, adolescents demonstrated improvements
number of events in the stories at pre- and post-test. in recall of important events of a verbally presented fable
Adolescents created stories with a greater number of events and in the global coherence of their written recall, sug-
in the post-test condition, t(22) = 5.26, p = .001, indicat- gesting that they were attending to story events and pro-
ing that stories were longer after the SMI. cessing these events in a way that helped them structure
important information for future use. In addition, adoles-
Goal-Based Categories cents generated a significantly greater number of explana-
tory and elaborative inferences during recall of the post-test
A paired-samples t test was conducted for each goal-based fable than during recall of the pre-test fable. The increase
story grammar category, including goal-based events, in the number of explanatory and elaborative inferences
goals, attempts, or outcomes. There were no significant created during the post-test session suggests that the SMI
improvements in the inclusion of any goal-based categories assisted adolescents in making appropriate and reasonable
from pre-test to post-test, all ps [ .05. implicit connections among story events that are vital to
comprehension. Finally, when included as a covariate in
Nongoal-Based Categories analyses, story mapping homework scores accounted for
significant variance in recall of story events and generation
A paired-samples t test was conducted for each nongoal- of explanatory inferences. These findings suggest that those
based story grammar category. Adolescents included a who performed well in completing the story map

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homework made more significant improvements on pre– Narrative comprehension deficits have been found at young
post assessments of narration skills. Although this was not ages in those with ADHD (Berthiaume et al., 2010), with
a randomized controlled trial, these pilot results are very some evidence that the gap between individuals with ADHD
encouraging. and their non-ADHD peers may widen over time (Bailey,
It is possible that these improvements in narrative Lorch, Milich, & Charnigo, 2009). By adolescence, long-
comprehension skills are due to two important components standing narrative comprehension deficits are unlikely to be
of the current work: the visual-organizational component completely remedied with brief treatment.
of the story maps and the repeated, guided teacher feed- One of the strengths of the current study is the use of an
back with the story map during the intervention. The story intervention directed at improving goal-based narrative
map is a visual display of the story components. The tea- comprehension in a population known to exhibit specific
cher could use the story map to direct attention toward goal deficits in narrative comprehension. Previous interventions
structure categories with the purpose of improving atten- that have used a story map as a means to improve recall
tion to important information and organizing this infor- have shown promising results for children with specific
mation for later retrieval. In addition to the story map itself, learning problems (Boulineau et al., 2004; Idol & Croll,
this protocol provided repeated practice of skills and 1987), and the story map has shown evidence of being a
feedback on completed story maps across ten sessions, potentially useful contribution to efficacious reading
thereby ensuring that adolescents recognized and corrected treatment programs in the school system (DuPaul et al.,
errors in their use of the story map at regular intervals. 2006). This is the first study to demonstrate that critical
Combined use of this strategy and reinforcement of skills elements of recall may be improved among adolescents
overtime may have worked together to promote gains. with ADHD by instruction and practice in the use of a story
In contrast to improvements in recall, adolescents did map as an organizational tool. The current results are
not show the same improvements in their creation of a particularly notable given what previous research has
story without use of a prompt. This is not surprising, given indicated about the typical effectiveness of interventions
that free writing of a story without prompts is considered a for those with ADHD. Though effective for some academic
challenging task for individuals with ADHD (Freer et al., indices (Evans et al., 2001; Pelham et al., 2013; Sibley
2011). Although stories improved in length (significantly et al., 2011), typical treatments for ADHD such as stimu-
more events and nongoal-based events from pre- to post- lant medication or studying and note-taking skills inter-
test), they were not improved in ways that suggest a ventions appear ineffective for improving goal-based
stronger adherence to the goal structure of a story. This narrative comprehension (Bailey et al., 2011; Derefinko
may be due to the fact that the SMI was better adapted to et al., 2009; Evans et al., 1995; Lorch et al., 2004). Typical
the demands of a recall task. That is, the teachers discussed treatments seem to help children and adolescents with
how using story maps could help the adolescents remember ADHD produce more information, but have not specifically
information and structure essays about existing stories. improved goal-based narrative comprehension. Results
Although adolescents completed regular writing assign- from this study suggest that the SMI may help those with
ments, teachers had fewer opportunities to address how to ADHD to build a coherent story representation, thus
create a story based upon character’s goal. Despite non- improving recall of important events, generation of infer-
significant results, development of the story map inter- ences, and coherence of recalls. All of these improvements
vention could be better adapted to serve story creation. For have promise for facilitating academic success.
instance, like the self-regulated strategy development
(SRSD) model (Harris & Graham, 1996), the story map Limitations and Future Directions
could be provided prior to writing and used as a develop-
ment tool for the generation of story ideas. After the story There were several limitations of the current study. First,
is ‘‘mapped,’’ the adolescent can begin writing. Although due to the fact that this study was conducted within the
exploratory, such tailoring of interventions could be very context of a broader treatment program, there was an
useful for task-specific skills. unavoidable sacrifice of experimental control. Because all
It may also be the case that the SMI should be provided for participants were a part of this clinic-based program and
a longer duration or with greater intensity for story creation the SMI was conducted as a mandatory part of the program,
gains to be achieved. The literature has consistently indi- it was not possible to include a no-treatment comparison
cated that the intensity and duration of treatment for ADHD group. Therefore, although adolescents with ADHD dem-
should reflect the chronic nature of the disorder (Pelham & onstrated significant improvements in fable recall across
Fabiano, 2008); limits on the effectiveness of the interven- tests, we were unable to compare these results with ado-
tion may reflect the deep-seated nature of the narrative lescents with ADHD who had received the intensive clinic-
comprehension deficits for individuals with ADHD. based program but had not received the SMI intervention,

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or with adolescents with ADHD who had received neither It is also important to address narrative comprehension
of these interventions. Future work should include com- deficits among other age groups with ADHD. The current
parison groups to better understand the magnitude of these exploratory work evidenced improvements for adolescents
gains over and above gains made by the summer treatment aged 12–16, but introducing this type of intervention at
program, and gains made by simple maturation. younger ages may have the potential to ameliorate narra-
Relatedly, another notable limitation of the current work tive comprehension deficits before they have incremental
is that it is difficult to evaluate whether the SMI or the impacts on academic functioning. Alternatively, utilization
summer treatment program was responsible for improve- of similar techniques for individuals entering college may
ments in narrative comprehension. For example, the summer be an important addition to their writing skills that will
treatment program for adolescents with ADHD included promote coherence in written assignments. To accomplish
behavioral modification to improve attention and reduce this, future work would do well to develop age-appropriate
classroom-incompatible behavior. It is possible that the other story maps and evaluate of the effectiveness of these maps
forms of intervention adolescents received may have had a in a broad range of age groups.
cumulative positive effect on story narration; however, this
was partly controlled for in analyses utilizing SMI home-
work grades. Further study in this area would benefit from Conclusion
utilizing the SMI in isolation (e.g., not as a part of a clinic-
based program), or in other structured settings, such as an This study explored the use of a story mapping intervention
addition to the school curriculum, to determine the true effect to reduce narrative comprehension deficits in adolescents
of this treatment and possible cumulative effects of this with ADHD in the context of an intensive, clinic-based
treatment when combined with other intervention strategies. treatment program for ADHD. The story mapping inter-
The fact that the SMI was conducted in the context of a vention improved several aspects of adolescents’ recall of a
broader treatment program also limited the amount of fable, including the number of events recalled, coherence,
experimental control over study factors such as the and the generation of inferences, and covariate analyses
counterbalancing of study measures and additional inter- with homework scores suggest that these improvements
ventions that were provided as a standard part of the were related to higher story map homework scores.
summer program. Because classroom placement in the Although preliminary, these results are encouraging, given
treatment program was based upon age and gender of the the chronic nature of ADHD and the long-standing nature
adolescents, counterbalancing measures could not occur of ADHD-related academic deficits. Despite gains in recall
without introducing other study confounds. Thus, one fable skills, narrative comprehension improvements did not
was used for baseline assessment, and the other was used generalize to story creation. However, this intervention
following the intervention. Future studies of the SMI could be more effectively tailored to promote the focus of
should address this issue to ensure that the characteristics goal-based events in writing assignments by having ado-
of a specific story were not responsible for gains. However, lescents develop ideas utilizing the story map as a guide
in the current study, the fables were very similar to those before writing. Based upon the design of this study, it
used in past research in which the effect of importance appears possible to use the story mapping intervention as
levels on recall did not differ as a function of the specific an effective part of a writing class in a secondary school
fables (Bailey et al., 2011). Thus, it is unlikely that fable setting, and future work would do well to use this inter-
effects are responsible for the pattern of recall vention in more traditional education settings where this
improvements. type of intervention is likely to be implemented as a part of
In addition, the nature of this program allowed 8 weeks special services for individuals with ADHD.
for the intervention, a considerable period given typical
resources. Future work in this area could explore whether Acknowledgments The authors gratefully acknowledge research
support from the National Institute on Drug Abuse of the National
an SMI could be implemented in a setting where adoles- Institutes of Health (DA007304 and T32DA035200) and from the
cents typically spend substantial amounts of time (e.g., Institute of Education Sciences, US Department of Education
school or after-school programs), or whether the effec- (R305A120171) to the University of Kentucky. The content is solely
tiveness of the SMI could be maintained when much less the responsibility of the authors and does not necessarily represent the
official views of the National Institutes of Health or the US Depart-
time is available (e.g., as part of outpatient treatment or ment of Education.
tutoring). These preliminary results suggest that 10 practice
sessions were enough to make significant gains, but
exploration of whether these gains can be achieved in Appendix
fewer session would be valuable to understanding how and
where this form of intervention should be offered. See Fig. 3.

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Fig. 3 Story map using goal-based categories

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