Health and Disability

Narrative retelling in children with neurodevelopmental disorders: Is

there a role for nonverbal temporal-sequencing skills?

JAKOB �ASBERG JOHNELS,1,2 BIBBI HAGBERG,1 CHRISTOPHER GILLBERG1 and CARMELA MINISCALCO1,3

1Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden2Department of Psychology, University of Gothenburg, Sweden3Division of Speech and Language Pathology, Institute of Neuroscience and Physiology, University of Gothenburg, Sweden

�Asberg Johnels, J., Hagberg, B., Gillberg, C. & Miniscalco, C. (2013). Narrative retelling in children with neurodevelopmental disorders: Is there a rolefor nonverbal temporal-sequencing skills? Scandinavian Journal of Psychology.

Oral narrative retelling is often problematic for children with communicative and neurodevelopmental disorders. However, beyond a suggested role oflanguage level, little is known about the basis of narrative performance. In this study we examine whether oral narrative retelling might be associatednot just with language level but also with skills related to nonverbal narrative temporal sequencing. A diagnostically heterogeneous sample of Swedish-speaking children with a full scale IQ >70 was included in the study (N = 55; age 6–9 years). Narrative retelling skills were measured using the threesubscores from the bus story test (BST). Independent predictors included (1) temporal sequencing skills according to a picture arrangement test and (2)a language skills factor consisting of definitional vocabulary and receptive grammar. Regression analyses show that language skills predicted BST Sen-tence Length and Subordinate Clauses subscores, while both temporal sequencing and language were independently linked with the BST Informationsubscore. When subdividing the sample based on nonverbal temporal sequencing level, a significant subgroup difference was found only for BST Infor-mation. Finally, a principal component analysis shows that temporal sequencing and BST Information loaded on a common factor, separately from thelanguage measures. It is concluded that language level is an important correlate of narrative performance more generally in this diagnostically heteroge-neous sample, and that nonverbal temporal sequencing functions are important especially for conveying story information. Theoretical and clinical impli-cations are discussed.

Key words: Narrative, language impairment, autism, ADHD, temporal sequencing, ESSENCE, bus story test.

Jakob �Asberg Johnels, Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Kungsgatan 12, SE-41119 G€oteborg, Sweden. Tel: 0046-31-34 25 97; fax: 0046-31- 34 25 979; e-mail: psyjaas@psy.gu.se

INTRODUCTION

Narrative retelling has been referred to as “integrated communi-cative performance” (Culatta, Page & Ellis, 1983, p. 66), and itsdevelopment – or lack thereof – is of great interest to develop-mental researchers from several scientific disciplines, includingpsychology, language pathology, psychiatry and general neuro-science. Insight into the nature of narrating is, for numerous rea-sons, also important for many professional groups workingdirectly with children in clinics and schools. For instance, narra-tive retelling has been shown to be an important longitudinalpredictor of communicative (Bishop & Edmundson, 1987) andacademic skill development (Fazio, Naremore & Connell, 1996).More generally, Botting (2002, p. 1) suggested that narrativeassessment may be “one of the most interesting and ecologicallyvalid ways in which to measure communicative competence bothin normal populations and in clinical groups.” Prior research hasclearly shown that narrative retelling (e.g., Botting, 2002,Miniscalco, Hagberg, Kadesj€o, Westerlund & Gillberg, 2007) orother tasks of oral narrative production (e.g., Norbury & Bishop,2003) present a great challenge for children with communicationand neurodevelopmental disorders, for example, language delay(LD)/impairment (LI), attention-deficit/hyperactivity disorder(ADHD), or autistic disorder or other autism spectrum disorders(ASD).There is currently evidence to suggest that children’s language

level plays an important role in, and possibly also puts a limiton, narrative ability. For instance, Heilmann, Miller, Nockerts

and Dunaway (2010, p. 161) recently examined language andnarrative retelling skills in typically developing schoolchildren,and noted an “important relationship between narrative organiza-tion and vocabulary skills.” In order to be able to encode andreproduce a complex oral narrative, where events are organizedhierarchically in terms of temporal and causal/enabling relations,it may also be necessary for children to have acquired sufficientsyntactic skills to represent and express such relations (Bishop &Donlan, 2005). Norbury and Bishop (2003) examined narrativeproduction in different diagnostic child groups and found thatlevel of language skill was a more important correlate of perfor-mance than was the specific clinical diagnostic category (i.e.,pragmatic language impairment, ASD, LI versus typicalcontrols). Furthermore, Botting (2002) reported very strongcorrelations between receptive and expressive grammar, on theone hand, and a measure of narrative story structure, on theother hand, in a sample of children with pragmatic languageimpairment.In the present study, we examine whether oral narrative retell-

ing difficulties in a heterogeneous sample of children with com-municative difficulties and neurodevelopmental disorders mightbe associated with not only language level but also with skillsrelated to nonverbal narrative temporal sequencing. Several linesof research on typically or atypically developing samplesmotivate this hypothesis.First, existing neuroscientific research suggests a possible

distinction between language and temporal-sequencing functionswithin the overall narrative ability. A study where fMRI data

© 2013 The Scandinavian Psychological Associations

Scandinavian Journal of Psychology, 2013 DOI: 10.1111/sjop.12067

were collected while typically developing adults produced oralnarratives showed activation in both language-related areas andthe inferior frontal cortex bilaterally (Troiani, Fern�andez-Seara,Wang, Detre, Ash & Grossman, 2008). The authors argued thatlanguage and temporal-sequencing skills must interact success-fully in order to produce an understandable and coherent narra-tive, and that the latter brain region might play a role as atemporal-sequencing resource, which helps to organize the narra-tive content based on knowledge of story structure (cf., Mar,2004, for a review).Second, research into the bases of children’s oral narrative

comprehension has indicated that this overall ability, quite differ-ent from general language skills, also includes a distinct set ofcognitive processing skills (Cain, Oakhill & Bryant, 2004;Kendeou, Lynch, van den Broek, Espin, White & Kremer,2005). Specifically, in order to construct a coherent mental repre-sentation of the situation described in a narrative, children mustefficiently identify and infer temporal and causal relations withinthe story context (Cain et al., 2004), and there is some evidenceto suggest that these underlying processes are the same acrossdifferent media, i.e. across aural, televised and written narratives(cf., Kendeou, van den Broek, White & Lynch, 2007; van denBroek, Kendeou, Kremer et al., 2005). According to van denBroek et al. (2005), these findings have important implicationsfor the assessment of comprehension skills in children as theysupport the use of non-verbal materials, such as televised or pic-torial narratives, where the influence of language skills in com-prehension is kept to a minimum. This line of reasoning mightbe critical also in the context of the present study, given (i) asso-ciations between comprehension and narrating impairments evenafter controlling for language level (e.g., Cain, 2003), (ii) com-prehension difficulties being common in children with neurode-velopmental disorders (Bishop & Adams, 1992; Miniscalcoet al., 2007) and (iii) narrative retelling being an integrated skilllikely to reflect both the ability to encode and comprehend a nar-rative and to retell it properly (Culatta, et al., 1983). The notionof narrative being a modality-general cognitive process has alsobeen presented in recent theoretical work on the comprehensionof sequential pictorial narratives (Cohn, 2013). Guided by earlyworks on narratology (cf., Herman, 2003), syntactic theory (e.g.,Jackendoff, 1977) and schema theory as applied to event under-standing (e.g., Schank & Abelson, 1977), Cohn’s theory seeks toexplain how people can integrate the flow of events when “read-ing” sequential picture stories. For instance, the theory describesnecessary prerequisites for linking the “bottom up” contents ofthe panels to a more general canonical schema. Although theframework is developed primarily to account for comprehensionof pictorial sequential narratives, it is hypothesized that “thesestructures permeate across film and verbal discourse as well”(Cohn, 2013, p. 34).Third, there are studies on children with neurodevelopmental

disorders (e.g., Diehl, Bennetto & Young, 2006: high-function-ing autism; Tannock, Purvis & Schachar, 1993: ADHD) showingthat children who demonstrate normal language skills may nev-ertheless retell oral narratives that are significantly less coherentand/or structurally complex than the narratives of typicallydeveloping comparison children with the same language level.These studies strongly suggest that there is “something

cognitive” – besides language – that is important for effectiveand coherent narrative retelling in these children. Here wepropose that this “something” might be nonverbal – or modality-independent – skills in narrative temporal sequencing.Most studies in the field have attempted to address potential

difficulties with macro-level temporal organization of oral narra-tive information within a story-grammar framework (Stein &Glenn, 1979). In such research it has been found that childrenwith LI (Merritt & Liles, 1987; Botting, 2002), ADHD (Tannocket al., 1993) and ASD, amongst other diagnostic groups(Estigarribia, Martin, Roberts, Spencer, Gucwa & Sideris, 2011),often show less skilled use of story grammar elements in theirnarratives (e.g., proper endings). However, as story grammarevaluation is based on the oral narrative task itself (which,obviously, is high in linguistic load), it is difficult to clearlyestablish an independent role of temporal sequencing in thesestudies. A recent study (Marini, Martelli, Gagliardi, Fabbro &Borgatti, 2010) of narrative ability in nine children and adultswith William’s syndrome (WS) provides a potentially promisingalternative in terms of assessment. While the group with WSshowed (relatively) good phonological, lexical and syntacticskills, they were outperformed by mental age-matched typicallydeveloping children on measures assessing global coherenceand lexical informativeness in their oral narratives. Moreover,in the WS group, making fewer semantic mistakes during nar-rative production was linked with a higher picture arrangementsubtest score on one of the Wechsler intelligence scales. Asthis subtest is a completely nonverbal (pictorial) narrative pro-duction task, it should constitute a valid index of temporalsequencing independently of language skills and the oral narra-tive measure itself. Picture arrangement is furthermore pre-sumed to reflect frontal lobe functioning (McFie & Thompson,1972).

Specific aims and hypotheses in the current study

To our knowledge, previous research has not included nonverbaltests, for example, picture arrangement tasks, as a means ofdirectly testing the predictive role of narrative temporal sequenc-ing versus language for oral narrative retelling ability in childrenwith neurodevelopmental and communicative disorders. Hence,this was the aim of the present study. We assessed narrativeretelling ability using one of the most commonly used instru-ments available: the bus story test (BST) (Swedish version ofRenfrew, 1997: Svensson & Tuominen-Eriksson, 2000). TheBST includes three subscores assessing different aspects of nar-rative ability. The length and complexity of the sentences in thechild’s narrative retell are represented by the Sentence Lengthand Subordinate Clauses subscores, respectively. The Informa-tion subscore is a measure of the child’s ability to unambigu-ously retell critical story elements. We examine how thesubscores from BST were related with independently assessedindexes of language skills and picture arrangement/temporalsequencing skills. As the subscores for Sentence Length andSubordinate Clauses appear closely related to the child’s linguis-tic maturity, we expected them to be related with language skills.For BST Information, we reasoned that there might be similar,or even the same, processing demands for conveying and

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organizing story information in oral and pictorial narratives.Hence, the Information subscore might be expected to be linkedto results on the picture arrangement subtest in addition to lan-guage skills.

MATERIAL AND METHODS

Participants and study context

The study group comprised 55 Swedish-speaking children (47 boys, 8girls) with a mean chronological age of 7.44 (SD = .71; range 6.04–9.10). Initially, 61 children were tested. To be included in the study, afull scale IQ (FSIQ) in excess of 70 according to testing with the WISC-III (Wechsler, 1999) was required. Five children who tested below thislevel were excluded. A known biological-etiological cause of a child’scommunicative problems also precluded participation. Accordingly, onechild was excluded due to cerebral ataxia.

Nineteen of the participants were recruited from a community samplethat had been followed longitudinally from age 2.5 years when they hadbeen flagged for language delay in a general health care screening pro-gram. The other participants (n = 36) were patients at the Child Neuro-psychiatric Clinic (CNC) in the city of Gothenburg and had beenconsecutively recruited for this research project at the time of theirreferral. A clinical research team at the CNC, including a psychiatrist,psychologist and speech-language pathologist (SLP), conducted compre-hensive neuropsychiatric assessments of the community sample and theCNC sample (see Miniscalco et al., 2007, for details) and found a vari-ety of DSM-IV disorders among the 55 children: 8 with autistic disorder,7 with an atypical autism/autism-like condition, 6 with Asperger’s disor-der, 16 with ADHD combined type and 9 with ADHD inattentive type.In addition, nine of the children in the community sample had a historyof language delay without any other neurodevelopmental disorder.Although some of these children had normalized oral language skills atthe time of this study, the vast majority had continuing challenges in thearea of written language (Miniscalco, 2007), which is typical for childrenwith residual language difficulties (Bishop & Clarkson, 2003). We referto these children as having a history of language delay (hLD). Further-more, most children in the current study had very complex comorbiditypatterns. Gillberg (2010) recently introduced the term ESSENCE (earlysymptomatic syndromes eliciting neurodevelopmental clinical examina-tions) to refer to early manifested problems, such as language delay,attention difficulties or social-interactive difficulties. One theoretical andclinical motivation for the ESSENCE term is a high degree of overlapbetween these conditions in development, where major problems in onedomain often signal problems in overlapping domains concurrently orsome years later. The current sample closely resembles the ESSENCEcategory described by Gillberg. Taken together, the current sampleshould not be regarded as representing “pure cases” of each diagnosticcategory but is rather a heterogeneous sample of children flagged forvarious neurodevelopmental and communicative concerns. The verbal,performance and full scale IQs in the sample were as follows: VIQ:

M = 92.73, SD = 13.28, range = 64–136; PIQ: M = 94.31,SD = 15.69, range = 64–123; full scale IQ: M = 92.65, SD = 12.65,range = 71–133. For detailed clinical information for each child, seeAppendix.

Ethics

The research ethics committee in Gothenburg approved the study, andthe parents provided written informed consent.

Material

Language measures. We used the vocabulary subtest from the WISC-III.This test is a definition task dependent on both expressive and receptivelanguage skills; it is expressed in scaled scores around a normative mean

of 10 (SD�3). The average reliability coefficient (split half) reported inthe manual is 0.95. We also used the Test for the Reception Of Grammar(TROG) (Swedish version of Bishop, 1983: Holmberg & Lund€alv,1998). This test measures receptive skills exclusively, and involvesmatching a total of 80 orally presented sentences to the correct pictureout of a choice of four. Raw scores were converted into z-scores andthen standard scores (M = 100, SD� 15) based on means and standarddeviations reported in the manual. We used these language tests as bothare standardized and widely used in Sweden and because they are basedon international tests with robustly evaluated psychometric properties.For purposes of the conducting regression analysis, we combined thetwo language skills measures into a common factor score. This procedurecan be motivated, first, as factor scores are generally more reliable thanmanifest variables. Second, there are good theoretical motivations forcombining these measures as several studies have shown that differentlanguage tests tend to load on a single factor (e.g., Ramus, Marshall,Rosen & van der Lely, 2013). Third, by using a factor we circumventthe risk for multicollinearity in the regression analyses (i.e., the twolanguage measures do not need to “compete” with each other whenexplaining variance in narrative performance); this allows us to more eas-ily identify a role of language in narrating if there is one. In the principalcomponent analysis, the two tasks loaded on a single factor accountingfor 68% of the variance in the data set. This latent language skills factorwas used in the analyses (i.e., the correlation and regression analyseswith BST measures, but descriptive data is also presented for each testseparately).

Nonverbal temporal sequencing. The picture arrangement subtest fromthe WISC-III performance IQ (PIQ) scale was used to assess nonverbalnarrative temporal sequencing, allowing comparisons with the results inMarini et al. (2010), who also employed this task from the Wechslerscales (with specific version suited for the age of each subject). In thissubtest, the child is to sequence a set of cartoon pictures into stories thatmake sense. There are 3–5 pictures in each set of cartoon pictures andthere are 14 sets. The child gets 2 points for a correct set of picturescompleted within the time norm and 3 extra points for speed. After threefailures the test is stopped. The subtest is an efficiency measure in thesense that there is a time limit and bonus for speed. The average reliabil-ity coefficient (split half) reported in the manual is 0.89. Figure 1 showsthe practice set. Results are expressed in scaled scores around a norma-tive mean of 10 (SD� 3). The total PIQ score from the WISC-III wasalso calculated.

Narrative retelling. The SLP administered the BST (Svensson & Tuomi-nen-Eriksson, 2000), which is based on a story about a “naughty” bus.The test administrator tells the story by using 12 cartoon pictures, withthree pictures per page. The child is then asked to retell the story whilehe or she looks at the pictures. The respondent’s narration was video-taped using a SONY Handicam DCR-TRV50E and an external micro-phone. Orthographical transcription was done according to the Swedishmanual (Svensson & Tuominen-Eriksson, 2000). The BST provides threenorm-referenced subscores. Following the procedure described in themanual, the five longest sentences were selected in each sample, and themean value was calculated as the Sentence Length score. The number ofSubordinate Clauses score was calculated, providing a measure ofexpressive grammatical complexity. The Information score reflects thenumber of pre-specified pieces of information given by the child.According to the manual (Svensson & Tuominen-Eriksson, 2000), theInformation subscore also reflects the child’s ability to comprehend theoriginal story. Furthermore, points were not given if a piece of informa-tion was provided in relation to the wrong picture. However, no suchinstances were observed. The maximum Information score is 54; themaximum scores on Sentence Length and Subordinate Clauses are notpossible to determine. The BST is standardized for Swedish childrenaged 3.9–8.5 years, and therefore does not fully cover the age range rep-resented in the present study. Furthermore, standard deviations are notreported for all ages for Sentence Length and Subordinate Clauses in theSwedish manual, which precludes calculation of norm-referenced scores.Hence, BST results are expressed in raw scores for these variables,

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Narrative retelling in children 3Scand J Psychol (2013)

whereas BST Information is also expressed in standard scores fordescriptive purposes when possible. Two independent coders, that is, twotrained graduate SLP students, who were blind to children’s main diag-noses, ages and TROG and WISC-III results, analyzed all narratives.Thirty-four percent of the narrative transcriptions were re-evaluated by athird trained SLP student for inter-rater reliability. The inter-rater reliabil-ities, as assessed with intra class correlations (single measure), wereexcellent at 0.97 –0.99 for all three BST subscores.

RESULTS

According to independent t-tests there were no significant dif-ferences between participants recruited from the community andparticipants recruited from the clinic on any of the three BSTmeasures (Information: t[53] = 0.18, p = 0.86; SubordinateClauses: t[53) = �0.07, p = 0.95 [equal variances notassumed]; Sentence Length: t[53] = �0.24, p = 0.81) or thepredictor variables (Language Skills Factor: t[53] = 1.01,p = 0.32; Picture Arrangement: t[53] = 0.01, p = 0.99). Hence,we completed the analyses using the whole sample rather thandividing participants into two groups based on where they wererecruited.

The mean results on PIQ, picture arrangement, vocabulary andTROG all fell slightly below the population mean (see Table 1).The group appeared to score low on narrative retelling, and par-ticularly for BST Information. Comparing the group’s raw meanscores with the normative values in the manual for Information,Subordinate Clauses and Sentence Length, they represent theperformance of children aged 5:4–5:5, 6:7–6:11 and 6:7–6:11,respectively. For 46 out of 55 participants it was possible tocalculate a norm-referenced standard score for BST Information.The mean score fell nearly 1.5 standard deviations below thenormative performance (M = 78.67, SD = 16.51). In addition,the mean BST Information raw score for the nine children whodid not have a standard score was not significantly different fromthose who did (t[53] = �1.31, p = 0.19), despite being signifi-cantly older (t[53] = �5.09, p < 0.001). Hence, it is safe to con-clude that the total sample scored poorly on BST Information.In the analyses, BST raw scores were corrected for age by

using the unstandardized residuals (calculated according to theprocedure described in White et al., 2006). The resulting scoresrepresent the narrative retelling scores that cannot be explainedby chronological age. Both before and after this procedure, we

Table 1. Correlations, and BST, TROG, and WISC III test findings (mean, SD and distribution) in 55 children

1. 2. 3. 4. 5. 6. 7. 8. M (SD) Kurtosis Skew

1. BST Information 25.38(8.25)

�0.61 0.00

2. BST Subordinate Clauses 0.64** 3.96(2.33)

�1.28 �0.08

3. BST Sentence Length 0.57** 0.70** 10.13(2.34)

�0.37 0.38

4. TROG 0.27* 0.44** 0.40** 98.21(17.43)

1.53 �1.04

5. WISC III Vocabulary 0.26 0.32* 0.39** 0.36** 9.40(2.38)

3.50 0.12

6. Language factor 0.32* 0.46** 0.48** 0.82** 0.82** 0.00(1.00)

4.34 �0.86

7. WISC III Picture Arrangement 0.36** 0.12 0.25 0.08 0.11 0.12 9.84(3.24)

0.19 �1.03

8. WISC III Performance IQ 0.26 0.18 0.27* 0.19 0.20 0.24 0.71** 94.31(15.69)

�1.07 �0.01

Notes: *p < 0.05, **p < 0.01Variables 1, 2, 3 are expressed in raw mean scores; in the correlations the raw scores are residualized for chronological age. Variables 4 and 8 are expressedin standard scores around a normative mean of 100 (SD � 15), and variables 5 and 7 in scaled scores around a normative mean of 10 (SD� 3).

Fig. 1. The completed practice set from the picture arrangement subtest in WISC-III. Printed with permission from Pearson Sweden.

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4 J. �Asberg Johnels et al. Scand J Psychol (2013)

confirmed that the BST variables were approximately normallydistributed according to histogram inspection and calculation ofskewness and kurtosis.Pearson correlations between all measures of interest (Table 1)

as well as three sets of regression analyses were performed withthe corrected BST subscores as dependent variables (Table 2). Inthe regression analyses we entered the language skills factor andpicture arrangement simultaneously as predictor variables. Ascan be seen in Table 2, the two independent variables were dif-ferentially linked with BST subscores. BST Subordinate Clausesand BST Sentence Length were only predicted by languageskills. BST Information was predicted by both language skillsand picture arrangement/temporal sequencing.1

There was great variability in nonverbal temporal sequencingskills in the sample, with the average picture arrangement perfor-mance being close to normative levels for the population. Thus,we next subdivided the sample based on their picture arrange-ment performance. Fourteen participants had a scaled score of 7or below on picture arrangement (i.e., at least 1 SD below thenormative mean), while 41 participants scored above this cut-off.Means, standard deviations and statistical details from groupcomparisons are presented in Table 3. No differences werefound between the two subgroups on the language skills factoror on the BST Subordinate Clauses and BST Sentence Lengthsubscores. However, a significant difference was found on BSTInformation with the poor picture arrangement subgroup havinglower results.Finally, an additional principal component factor analysis was

conducted in the total sample with the BST subscores, TROG,vocabulary and picture arrangement as included variables. Theanalysis is purely data driven, and allowed us to examine more

directly whether the three BST subscores are separable dimen-sions with (partly) different underlying correlates. Two factorswith eigenvalues >1 were extracted by means of varimax rota-tion, accounting for a total of 65% of the variance in the dataset. The first factor accounted for 48% of the variance, and BSTSubordinate clauses (0.77), BST Sentence length (0.72), TROG(0.75) and vocabulary (0.67) had their highest loading here. Thesecond factor accounted for 17% of the variance, and BST Infor-mation (0.68) and picture arrangement (0.86) had their highestloading here. BST Information had some cross-loading also onthe first factor (0.50).

DISCUSSION

The result of this study confirms previous findings that languageplays an important role in the narrative difficulties often experi-enced by children with communication difficulties and neurode-velopmental disorders (e.g., Botting, 2002; Norbury & Bishop,2003; Smith Gabig, 2008). Specifically, we find that an index oflanguage skills independently predicted BST Sentence Lengthand Subordinate Clauses results. For the BST Information sub-score, we provide new evidence for a more complex pattern. Inregression analysis, this subscore was linked with language skillsand the (nonverbal) picture arrangement subtest from the WISC-III. Further, children with poor picture arrangement scoreddistinctively poorer on BST Information. Finally, in the principalcomponent analysis, the picture arrangement and BSTInformation scores loaded together on a factor separate from theother variables considered. We hypothesized that picture arrange-ment reflects narrative temporal sequencing, a skill independentof basic language skills. The findings obtained support the

Table 2. Outcome from regression analyses (method: enter) with the three BST narrative subscores as dependent variables

Information Sentence length Subordinate Clauses

R2 / F t b R2 / F t b R2 / F T b

Language factor 2.30 0.29* 3.81 0.46** 3.66 0.45**Picture arrangement 2.59 0.32* 1.66 0.20 0.51 0.06

0.21 / 0.27 /9.55** 0.22 /6.80** 7.15**

Note: N = 55.*p < 0.05,**p < 0.01

Table 3. Means and standard deviations in subgroups defined by poor versus normal picture arrangement/temporal sequencing

Group

Poor picture arrangement (n = 14) Normal picture arrangement (n = 41) Statistical comparison

Picture arrangement 5.8 (0.7) 11.2 (2.5) t(53)a = �12.53, p < 0.001Language factor �0.3 (0.6) 0.1 (1.1) t(53) = �1.1, p = 0.27BST Information (age corrected) �6.3 (6.4) 2.14 (7.3) t(53) = 3.8, p < 0.001BST Sentence length (age corrected) �0.9 (1.7) 0.29 (2.5) t(53) = �1.6, p = 0.12BST Subordinate Clauses (age corrected) �0.8 (2.3) 0.27 (2.3) t(53) = �1.5, p = 0.13

Note: Picture arrangement is expressed in scaled scores around a normative mean of 10 (SD� 3).aEqual variances not assumed.

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Narrative retelling in children 5Scand J Psychol (2013)

notion that there is a robust association between children’sability to nonverbally organize a picture story and their ability toconvey story information during oral narrative retelling. Level oflanguage skill is an important correlate of narrative retelling per-formance more globally, but especially for sentence length andgrammatical complexity. We believe that these findings are ofinterest for several reasons.First, the assessment of nonverbal narrative temporal sequenc-

ing by use of the picture arrangement subtest is important froma methodological perspective. Other than the study by Mariniet al. (2010) (with a small mixed sample of children andadults), we are not aware of any other research that hasincluded behavioral indices of temporal sequencing in the con-text of oral narrating. Furthermore, the current study appears tobe the first to control for language skills in relation to the narra-tive measure. We now have the beginnings of an empirical basisfor assuming that narrative difficulties in children cannot beexclusively language-based but are comprised also by more fun-damental difficulties in expressive temporal sequencing. Fromthe perspective of our results, it is unfortunate that picturearrangement has been removed from the most recent version ofthe WISC (i.e., WISC IV).Second, our results provide interesting links to recent research

on narrative discourse comprehension in children. Arguably,general language level certainly constitutes an important correlateof listening and reading comprehension of narrative discourse(e.g., Cain et al., 2004, Nation, Adams, Bowyer-Crane & Snow-ling, 1999). However, recent studies examining comprehensionacross additional media (i.e., pictures and movies) have shownthat certain integrative processes “are remarkably similar acrossmedia and develop in parallel with basic language skills”(Kendeou et al., 2007, p. 35). We believe that the results of ourstudy indicate that narrative production also requires an underly-ing well-functioning set of cognitive processes that transferacross modalities for their expression (i.e., across oral and picto-rial narratives). It could also be the case that some formof schema-based knowledge about typical event structures(Rumelhart, 1980; Schank & Abelson, 1977) or canonical narra-tive schemas shows up in the child’s narration in both modalities(cf. also Cohn, 2013). Related ideas have appeared in thewritings of schema theorists, but there has been little in the wayof direct evidence.An obvious implication of our results is that future research

should aim at unraveling what the cognitive and experiential fac-tors are that underlie performance in the picture arrangementsubtest – something that we still know very little about – andhow these are related to the neuropsychology of different neuro-developmental disorders. For example, while picture arrangementresults have been linked to frontal lobe functioning (McFie &Thompson, 1972), little is known about the relationships withexecutive functions more generally. Importantly, all specificdiagnostic categories included in the present study group areknown to often display executive dysfunctions. In particular, itmight be important to look further into working memory as ithas been linked with temporal sequencing ability (Houghton,Cordin, Durkin & Whiting, 2008) and with narrative-retellingskills (Smith Gabig, 2008) in children with neurodevelopmentaldisorders. However, it is not clear whether working memory, at

least its verbal component, can be separated from language skills(Smith Gabig, 2008; Nation et al., 1999). Another issue worthyof further research is the relationship between picture arrange-ment, narrative retelling and “pragmatic language skills,” that is,other measures of the child’s ability to use language for commu-nicative purposes. It is interesting to note in this context thatNorbury and Bishop (2003, p. 309) found that the pragmaticskills of the control group (as assessed with the children’scommunication checklist; CCC; Bishop, 1998) were stronglycorrelated to the semantic score of the narrative task (apparentlysimilar to the Information subscore in the current study), sug-gesting “perhaps that good pragmatic abilities facilitate one’sability to determine and convey relevant information.” However,Norbury and Bishop found little evidence for this relationship intheir clinical groups, suggesting that further research needs to beconducted on this link in such samples. Finally, Conson, Salzanoand Grossi (2011) argued that experience with comic strips andmagazines can boost the development of picture arrangementskills. Unfortunately, we have no data on reading and mediahabits in our sample, but it might perhaps be speculated thatchildren who spend a lot of time reading comics and other illus-trated narratives will develop a more elaborate knowledge ofstory structure, which in turn could support their picture arrange-ment and their narrative retelling skills.There are some limitations to the present research. First, our

analyses were based on a diagnostically heterogeneous group ofchildren. Future research could attempt to replicate the results foreach diagnosis separately, which would require larger samplesizes.2 Second, our study cannot determine whether narrativeskills in typically developing children are also influenced by bothlanguage and temporal sequencing skills. However, as all partici-pants in the study had IQs in the non-intellectually disabled range,it does not seem likely that IQ in and of itself would influence theoverall conclusion that some narrative skills in children dependboth on language and temporal sequencing. Nevertheless, ourfindings are clearly in need of replication in a large sample ofchildren from the general population. Third, this study onlyutilized a picture-elicited retelling task to assess narrative ability.Therefore, the results presented might not generalize to othercommonly used narrative production tasks (cf., e.g., Bishop,2004; Mayer, 1969). Fictional narratives can be elicited either asnarrative generation or narrative retelling with or without picto-rial support. While narrative generation is sometimes consideredto be more demanding than narrative retelling since it emergesfrom the child itself without external input from an adult model(Leinonen, Letts & Smith, 2000), little systematic research hasbeen conducted where processing demands have been compared.Whether different formats for narrative assessment place differentdemands on the child’s skills in language, temporal sequencingand other neuropsychological functions such as memory is there-fore an important topic to examine in future research. Finally,although this study has provided important clues on the associa-tions between language, nonverbal sequencing and narrativeretelling performance, it should be remembered that the resultsare correlational in nature. Hence, better insight into the causalityof these associations is necessary before the results have directclinical/educational significance (for example in terms of fosteringoral narrative skills through nonverbal pictorial intervention).

© 2013 The Scandinavian Psychological Associations

6 J. �Asberg Johnels et al. Scand J Psychol (2013)

NOTES1 It was not considered meaningful to include the total PIQscore in the regression analysis given that (i) picture arrangementformed part of the PIQ score and (ii) PIQ was not significantlycorrelated with BST Information in the bivariate correlation.2 We could not find any differences between the “major diagnosticcategories” making up our sample. Specifically, there were no sig-nificant differences when comparing children with ASD (n = 21),ADHD (n = 26) and LI/hLD (n = 9) on any of the variables ofinterest: Information: F(2, 52) = 0.05, p = 0.96; SubordinateClauses: F(2, 52) = 1.93, p = 0.15; Sentence Length: F(2,52) = 0.01, p = 0.99; Language Skills Factor: F(2, 52) = 0.47,p = 0.63; Picture Arrangement: F(2, 52) = 0.56, p = 0.57. A chi-square test on “major diagnostic group” over “picture arrangementsubgroup” also revealed no significant association, v2

(N = 55) = 1.07, p = 0.59. The verbal IQs and performance IQsin the three groups were as follows: PIQASD: M = 95.76, SD =15.72, range = 71–121; PIQADHD: M = 93.16, SD = 15.96,range =64–123; PIQLI/hLD: M = 94.11, SD = 15.69, range =64–123; VIQASD: M = 91.00, SD = 14.40, range = 64–136;VIQADHD = 93.00, SD = 13.24, range = 73–134; VIQLI/hLD:M = 94.56, SD = 11.83, range = 81–113. No significant differ-ences were obtained when comparing the major diagnostic catego-ries on the IQ scores. The samples were too small to allow foranalyses of performance differences between each specific diag-nosis (e.g. ADHD inattentive subtype versus autistic-like condi-tion etc.).Jakob �Asberg Johnels and Carmela Miniscalco contributedequally to this article.

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Received 27 September 2012, accepted 23 May 2013

© 2013 The Scandinavian Psychological Associations

8 J. �Asberg Johnels et al. Scand J Psychol (2013)

1APP

ENDIX

IDAge

Gender

Source

ofreferral

(Screenor

CNC)

Main

diagnosis

Other

diagnosesor

clinical

data

WISC-III

FSIQ

WISC-III

VIQ

WISC-III

PIQ

WISC-III

vocabulary

ss

WISC-III

Picture

arrangem

entss

BST inform

ation

BST Sentence

length

BST

Sub

clauses

TROG

Standard

score

17.08

♂Screen

ADHD

(IA)

DCD

/RWD

8679

977

511.00

9.00

1.00

110.71

28.01

♂Screen

ADHD(IA)

RWD

9595

979

1233.00

14.40

4.00

100.00

38.01

♂Screen

ADHD

(C)

RWD

102

94111

815

25.00

8.80

1.00

100.00

47.04

♀Screen

ADHD

(IA)

RWD

9987

114

1116

31.00

11.80

5.00

100.00

57.06

♂Screen

ADHD

(IA)

Tic

disorder

9587

105

1112

22.00

7.20

2.00

83.93

68.01

♂Screen

ADHD

(C)

DCD

/BIQ

8173

958

1113.00

8.20

1.00

109.38

78.06

♂Screen

ADHD

(IA)

9497

9111

1440.00

9.80

5.00

100.00

88.00

♂Screen

ADHD

(C)

DCD

/BIQ

7984

778

830.00

10.00

3.00

81.25

97.08

♂CNC

ADHD

(IA)

DCD/Autistic

traits

9482

109

613

38.00

13.40

6.00

94.64

108.00

♂CNC

ADHD

(C)

DCD/Autistic

Traits

8781

977

619.00

8.40

2.00

100.00

117.03

♂CNC

ADHD(C)

DCD

/Autistic

Traits

8491

8010

1222.00

9.60

1.00

89.29

126.08

♂CNC

ADHD(C)

DCD

9286

102

911

15.00

5.80

1.00

83.33

136.04

♂CNC

ADHD(IA)

132

134

123

1712

21.00

13.40

6.00

88.89

147.10

♂CNC

ADHD(C)

DCD/Autistic

traits

9192

9210

916.00

7.60

1.00

100.00

157.00

♂CNC

ADHD(C)

DCD

91105

7610

621.00

8.20

1.00

89.29

168.01

♂CNC

ADHD(IA)

BIQ

7483

709

531.00

12.40

8.00

118.75

177.03

♂CNC

ADHD(C)

DCD

/ODD

90109

7011

834.00

9.40

6.00

116.07

188.03

♂CNC

ADHD(C)

DCD

/Autistic

traits

8797

778

513.00

9.80

2.00

90.63

198.01

♂CNC

ADHD(C)

9591

100

99

30.00

9.00

2.00

100.00

207.06

♂CNC

ADHD(C)

BIQ

7691

649

624.00

9.40

3.00

67.86

217.05

♂CNC

ADHD(C)

ODD

109

112

103

1111

29.00

10.00

4.00

105.36

228.08

♂CNC

ADHD(C)

9896

102

99

38.00

13.40

5.00

109.38

238.09

♀CNC

ADHD(C)

DCD

/Autistic

traits

112

110

111

1414

39.00

13.80

7.00

137.50

247.04

♂CNC

ADHD(C)

DCD

/BIQ

/Tic

disorder

7177

719

521.00

10.80

3.00

78.57

259.10

♂CNC

ADHD(IA)

Autistic

traits/ODD

9392

9511

724.00

8.60

4.00

100.00

267.08

♂Screen

BIQ

7377

747

932.00

9.00

4.00

105.36

277.10

♂Screen

ADHD(C)

7882

7910

713.00

6.40

1.00

105.36

287.09

♂Screen

ADHD(C)

9994

106

109

25.00

11.80

4.00

116.07

296.08

♀CNC

Autism

ADHD(C)/DCD

9881

118

714

25.00

9.40

5.00

111.11

307.03

♂CNC

Aspergersyndrome

ADHD

(IA)/Tics

9394

948

837.00

11.80

8.00

110.71

316.05

♂CNC

Aspergersyndrome

ADHD(C)

93106

798

623.00

9.80

7.00

83.33

328.03

♂CNC

Autism

ADHD(C)

8688

868

1029.00

11.80

6.00

128.13

338.05

♂CNC

Autism

9787

109

815

26.00

12.80

6.00

118.75

348.10

♂CNC

Atypicalautism

ADHD

(C)/DCD/ODD

/RWD

9086

978

1135.00

8.80

7.00

62.50

356.10

♂CNC

Atypicalautism

ADHD

(C)/DCD

96104

8812

616.00

8.20

2.00

88.89

368.05

♀CNC

Atypicalautism

ADHD(C)

95100

9111

1434.00

13.20

6.00

100.00

377.11

♂CNC

Autisticlik

econdition

LI

9983

118

816

23.00

7.20

.00

89.29

388.00

♂CNC

Autism

ADHD(C)/BIQ

7664

971

1224.00

6.80

.00

43.75

398.06

♂CNC

Autism

ADHD(C)/DCD

/BIQ

7575

807

819.00

6.40

1.00

90.63

407.00

♂CNC

Aspergersyndrome

ADHD(C)/BIQ

8392

769

810.00

8.40

2.00

94.64

417.07

♂CNC

Autism

102

96109

119

28.00

12.20

6.00

89.29

427.11

♂CNC

Autistic

likecondition

LI

9483

108

814

23.00

13.00

4.00

83.93

© 2013 The Scandinavian Psychological Associations

Narrative retelling in children 9Scand J Psychol (2013)

439.05

♂CNC

Autism

105

99111

1012

22.00

9.90

7.00

107.89

448.06

♂CNC

Aspergersyndrome

Tourette

syndrome/BIQ

8092

719

59.00

7.00

1.00

90.63

457.06

♂CNC

Aspergersyndrome

ADHD/(C)

133

136

121

1415

28.00

16.40

7.00

121.43

468.02

♂CNC

Autism

DCD

9392

9913

1043.00

12.40

5.00

100.0

477.08

♂Screen

hLD

9592

100

98

25.00

10.00

7.00

94.64

487.11

♂Screen

hLD

97109

8314

835.00

13.00

5.00

110.71

497.03

♂Screen

hLD

87103

719

922.00

11.00

7.00

110.71

507.11

♀Screen

hLD

107

100

114

1010

28.00

10.40

6.00

110.71

518.07

♀Screen

hLD

105

105

105

1012

32.00

8.80

5.00

118.75

528.03

♀Screen

hLD

113

106

117

1010

33.00

9.20

5.00

118.75

538.00

♂Screen

hLD

BIQ

8188

7710

624.00

9.60

4.00

100.00

547.11

♂Screen

hLD

BIQ

8284

837

617.00

12.20

5.00

89.29

557.05

♀CNC

LI

8477

979

1316.00

8.00

1.00

51.79

Notes

DCD

=developm

entalcoordinatio

ndisorder;RWD

=reading

writin

gdisorder;BIQ

=bo

rderlin

eIQ

;ODD

=op

positio

naldefiantdisorder;LI=

language

impairment,

hLD

=history

oflanguage

delay;

CNC=Child

NeuropsychiatricClin

ic,Gothenburg

© 2013 The Scandinavian Psychological Associations

10 J. �Asberg Johnels et al. Scand J Psychol (2013)