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Text Structure Strategy for Expository Reading Comprehension: Case Study With an Adolescent With Noonan Syndrome

Shannon Hall-Millsa and Leesa Marantea

Purpose: This article describes the implementation of a text structure strategy approach to reading comprehension intervention to improve comprehension of expository texts for an adolescent with Noonan Syndrome and a history of developmental language disorder and reading disability. Method: The text structure intervention program was created for a feasibility study with adolescents who have language and literacy disorders. In the present case study, we investigated whether it was possible to improve expository text comprehension in a client with Noonan Syndrome and a history of significant needs in literacy. The text structure program leveraged the participant’s progressive knowledge

mmunication Science & Disorders, Florida State llahassee

ce to Shannon Hall-Mills: [email protected]

ef: Brenda L. Beverly

ember 12, 2020 ived February 11, 2021 il 13, 2021 /10.1044/2021_PERSP-20-00272

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and awareness of specific text structures and structure signal words for improved comprehension of compare- contrast texts. The participant attended 60-min sessions twice weekly for three weeks at a university clinic. Results: The participant demonstrated an increase in signal word identification as well as compare-contrast text comprehension. Conclusions: This preliminary case study demonstrates that a short-term, explicit text structure strategy intervention is feasible for treatment of reading comprehension difficulties. This study also provides support for future text structure research with adolescent language and literacy deficits secondary to medical complexities.

T here is an expanding body of research evidence that indicates text structure instruction can support im- proved reading comprehension for school-age chil-

dren and adolescents with language and learning disabilities (Hall-Mills & Marante, 2020; Hebert et al., 2016). This is an important area of research and practice because children with developmental language disorder (DLD) are 6 times more likely than their peers with typical language develop- ment to experience reading difficulties (Catts et al., 2002), likely due to the fundamental role of language ability in skilled reading (Nation & Snowling, 2004). The Simple View of Reading posits that reading comprehension is the result of decoding and linguistic comprehension (Gough & Tunmer, 1986). Many researchers have explored the application of the Simple View of Reading and substantiated the relative contributions of decoding and linguistic comprehension to reading comprehension (see Foorman et al., 2018; Lan- guage and Reading Research Consortium, 2015). Language

skills are central to the Simple View of Reading; a host of language skills contribute to breaking the written code while other language skills contribute to the construction of mental schemas of text which give rise to linguistic com- prehension (Kintsch, 2013). Students who have difficulty with comprehension without concomitant word reading deficits have been referred to as “poor comprehenders” with specific comprehension problems (Catts et al., 2006). These students have deficits in language comprehension, as shown via measures of listening comprehension and vocab- ulary and semantic processing (Catts et al., 2006; Nation et al., 2004). Reading comprehension deficits are common among adolescents with language and learning disabilities (Hall-Mills & Marante, 2020; McMaster et al., 2014), who may perform as much as five or more grade levels below their peers (Gartland & Strosnider, 2018). Thus, the Simple View of Reading helps explain the relationship between lan- guage skills and reading comprehension.

The construction–integration model of text compre- hension (Kintsch, 2013) explains how reading comprehen- sion is first a process of building an overall model of the information in the text using hierarchical relationships

Disclosures Financial: Shannon Hall-Mills has no relevant financial interests to disclose. Leesa Marante has no relevant financial interests to disclose. Nonfinancial: Shannon Hall-Mills has no relevant nonfinancial interests to disclose. Leesa Marante has no relevant nonfinancial interests to disclose.

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among ideas (represented as the text macrostructure) and second, an integration of the text microstructure and the reader’s background knowledge and experiences to form a situation model. Previous literature suggests that a lack of text structure recognition may be part of the reason com- prehension deficits persist as a child gets older (Gajria et al., 2007; Gersten et al., 2001). This is because a reader may struggle to infer meaning and create a mental representation of the text (Ray & Meyer, 2011). This is especially true for comprehension of expository text, which can be particularly challenging for students with language and learning disabil- ities to comprehend (Ehren, 2010). Compared to a narrative text, the expository text contains a higher concentration of unfamiliar content (Duke, 2010), advanced general (Tier 2) and domain-specific (Tier 3) academic vocabulary words, and greater overall lexical density and diversity (Lundine & McCauley, 2016). Expository text also consists of more complex syntactic structures, including nominalization and subordination that are used to build cohesion between ideas across sentences (Scott & Balthazar, 2010). Furthermore, the expository macrostructure differs by the subtype and purpose of the text, and each macrostructure has unique de- mands on a reader’s semantic and syntactic skills (Lundine & McCauley, 2016). Therefore, an explicit and systematic focus on expository text structure is a necessary and beneficial method for supporting adolescents’ reading comprehension.

Noonan Syndrome Incidence and Characteristics

Noonan syndrome (NS) is an autosomal dominant genetic disorder; approximately half of NS cases are linked specifically to a PTPN11 mutation (Pierpont et al., 2010). It is characterized by abnormalities in physical size, cardiac function, and facial and musculoskeletal features with an estimated incidence of 1/1,000 to 1/2,500 births (Pierpont et al., 2013). There is also a risk of hearing impairment. Despite its rarity, NS has been reported on more extensively than other more common neurodevelopmental disorders such as DLD (Bishop, 2010; McGregor, 2020). In fact, publications regarding NS increased 72% between the first and second decades of the millennium (McGregor, 2020). The increased attention to NS in the literature may be due to the severity of impact, which is estimated to be on aver- age slightly more severe than that of DLD (Bishop, 2010; McGregor, 2020).

The genetic mutations associated with NS alter the activation of proteins that regulate growth and development, resulting in a range of medical and developmental condi- tions. A common medical condition in individuals with NS is a heart defect. Developmental delays in speech, language, and literacy have also been noted in individuals with NS. Furthermore, they are at greater risk than typical peers for cognitive impairments (Lee et al., 2005; Pierpont et al., 2009), although the population of individuals with NS display a wide range of cognitive ability from moderate intellectual disability to superior intellectual ability (Pierpont et al., 2010). Moreover, attentional and executive functioning delays

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have also been documented in this population (Lee et al., 2005).

Language Profile As a clinically relevant population, children with

NS are among those at risk for language and learning diffi- culties. Prior studies of children with NS have offered a communication profile that includes DLD for some but not all children with NS (Lee et al., 2005; Wood et al., 1995). Pierpont et al. (2010) compared the distribution of standard scores for language from samples of children with NS to the normative population and found that the aver- age language functioning of children with NS was lower than the normative sample. While there were many children with NS functioning within the average range for language, more than 10% of the participants in Pierpont et al. (2010) had to- tal language standard scores in the range of 40–50 (based on the CELF:P-2 [Semel et al., 2004] and CELF-4 [Semel et al., 2003], with an M = 100 and an SD = 15), and 30% of the sample presented with significant impairments (be- low average range) in expressive and/or receptive language. Children with NS are at a greater risk than their peers for hearing loss, which can be expected to account for some variance in language functioning. Language abilities were significantly correlated with hearing ability (r = .64). Twenty- six percent of Pierpont et al.’s (2010) sample of children with NS had a history of hearing loss and 5% used hearing amplification. There did not appear to be any significant differences in their performance across specific areas of language; children with NS had similar levels of perfor- mance for grammatical and lexical tasks.

While there are patterns of language, cognitive, and learning difficulties in children with NS, there is not yet a consensus as to the language profile of this population. Pierpont et al. (2010) noted that while there were trends in their sample showing cognition and language levels were similar for most children with NS, this was not the case for all of them. The researchers concluded that due to individ- ual variability, they could not specify a language profile for the group as a whole and suggested that comprehensive speech and language evaluations be made available for all individuals diagnosed with NS. The risks and nature of DLD that may exist in children with NS have important implications for language intervention practices.

Text Structure Approaches to Instruction and Intervention

Evidence exists from several prior randomized and quasi-experimental studies regarding the effectiveness of explicit text structure instruction to bolster readers’ knowl- edge and comprehension of expository text structures (Bohaty et al., 2015). Children who have received explicit text structure instruction are better able to recognize distinct text structures, identify the key relationships in the text, recall a greater number of content units from reading passages, and show improvement on standardized measures of read- ing comprehension (Meyer et al., 2010; Ray & Meyer,

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2011). Text structure instruction has been provided with success to children in elementary and secondary grade levels. For students in the elementary grades, even a brief period (e.g., ≤ 5 min daily over 8 weeks, or 200 total mi- nutes) of text structure instruction with expository text results in comprehension gains (Connor et al., 2014; Williams et al., 2005, 2009). Students in the later grades also benefit from explicit comprehension instruction because the major- ity of reading content is from expository texts (Williams, 2018).

The collective evidence of the effectiveness of text structure instruction on children’s reading comprehension has been documented in two recent meta-analyses and a systematic review. Forty-five studies using text structure instruction with students across the full range of academic performance in Grades 2 through 12 were reviewed by Hebert et al. (2016). They found text structure instruction had a mean effect size of 0.56, 95% CI [0.43, 0.69]. Gains were maintained post intervention and use of the text structure strategy was evident in passages containing un- taught text structures. However, only five of the studies reviewed by Hebert et al. included participants with learn- ing disability (LD) in the later grades, with effect sizes ranging 0.62–2.17.

When text structure instruction is examined with sam- ples of students with LD, the effects are even stronger. Pyle et al. (2017) found an average effect size of 0.83 CI [0.76, 0.91] across 19 text structure instruction studies that included students with a LD in Kindergarten through Grade 12. How- ever, only three of those studies included students with LD in the later grades (Grades 6–12) with effect sizes ranging 1.08–2.27.

To extend the findings of Hebert et al. (2016) and Pyle et al. (2017), Hall-Mills and Marante (2020) conducted a sys- tematic review on the effects of explicit text structure instruc- tion for adolescents with or at risk for LD in reading. The findings of nine studies published in the span of 22 years indi- cated that most effect sizes were large, and effects ranged from small to large (d = 0.31–2.17; ƞp

2 = .05–.79) on exposi- tory reading comprehension outcomes measures. Across studies, text structure instruction was consistently more effective for reading comprehension than standard instruc- tion or business as usual conditions.

In the studies reviewed by Hebert et al. (2016), Pyle et al. (2017), and Hall-Mills and Marante (2020), the most frequently targeted text structure was compare-contrast. Of the studies reviewed by Hall-Mills and Marante, four of them focused on the compare-contrast structure for adoles- cents with or at risk for LD. In a single-subject, multiple- probe across participants design with four eighth graders with LD, Nealy (2003) provided explicit text structure intervention in seven, 20-min individual sessions across 4 days. Each in- tervention session included a review of the purposes and types of text structures, modeling the use of graphic orga- nizers and the process of identifying signal words and text patterns, think-aloud methods to engage with the partici- pants, and guided practice with reading passages. Reading comprehension was measured using a researcher-made

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measure of five comprehension questions balanced for textu- ally explicit and implicit items. The participants’ average median scores for the percent of correct responses to read- ing comprehension questions increased 40% from baseline to intervention phases and their score levels were maintained over a few weeks post intervention.

In a well-designed quasi-experimental study, Wilkins (2007) provided compare-contrast text structure instruction to 30 students at risk for reading disabilities in Grades 7 and 8. Instruction was provided in a whole classroom set- ting for 30-min sessions twice weekly for 2 weeks. For the first two sessions, instruction included an overview of the purpose and importance of expository text, identifying the main idea and other key idea units of a passage, and writing main idea statements. The same process was re- peated with a second passage. For the next 3 weeks, one treatment group also received instruction in paragraph re- statement. The treatment groups alternated the order of inter- vention between text structure and paragraph restatement. Both treatment groups improved in total idea units identi- fied in compare-contrast text. Effects were stronger when participants completed a period of paragraph restatement strategy instruction prior to the text structure strategy instruction.

In another quasi-experimental study, O’Connor et al. (2017) provided small group text structure instruction to 34 eighth grade students at risk for or with LD. Participants learned to construct main idea statements, and create, com- pare, and contrast paragraphs, and identify cause and effect relationships in history text. Text structure instruction was provided across 9 weeks, of which 3 weeks were devoted specifically to comparing and contrasting. Each session consisted of 15 min of comprehension strategy instruction and 20 min of reading and responding to compare-contrast history text. Students assigned to the text structure interven- tion outperformed the comparison group on standardized measures of reading comprehension and performed simi- larly to peers with typical learning development. The in- tervention group was significantly better at generating main ideas, comparing and contrasting people and events, identifying cause and effect relationships, and generalizing their comprehension to untaught content.

In a randomized control trial, Meyer et al. (2010) tested the effectiveness of a software program providing intelligent tutoring in text structure strategies to students in Grades 5 and 7, including students at risk for reading dis- abilities. They found that the text structure instruction was equally effective for both grade levels and reading compre- hension performance was better for students who received elaborated rather than general feedback.

The most salient elements of text structure instruc- tion that are supported by the current literature include struc- tured, explicit, scaffolded, and intensive instruction (Williams et al., 2014, 2016). Intervention approaches have incorporated strategy instruction for identifying text structure types includ- ing the identification of signal words, specifying the main idea, and recalling key details with the use of graphic orga- nizers. Many studies have incorporated direct vocabulary

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instruction and strategies for identifying genre-specific sig- nal words. Instruction in identifying the signal words is im- portant because subtypes of expository text rely on a unique text structure to communicate ideas, and each structure necessitates different signal words (Zwiers, 2010). Prior re- search has shown that it is possible to increase students’ understanding of comparative signal words after a period of text structure strategy instruction (Meyer et al., 2018).

Across the studies examined, text structure has been effectively targeted in whole-class, small-group, and one- on-one instruction. Instructional reading passages have focused on science, social studies, and history content. The instruction has been delivered by classroom teachers (O’Connor et al., 2017) or researchers (O’Connor et al., 2015; Wilkins, 2007), and self-paced web-based software (Meyer et al., 2010). The frequency and length of interven- tion sessions has ranged from a minimum of three, 30-min sessions in 1 week (Bakken et al., 1997) to a maximum of 40 consecutive days (8 weeks) of 45-min intervention ses- sions (O’Connor et al., 2017).

A variety of dependent measures for comprehension and signal word identification have been utilized in prior research. Comprehension outcome measures for compare- contrast text structure instruction for adolescents with or at risk for LD have included the generation of the main idea or number of idea units, norm- or criterion-referenced tests, curriculum-based measures, and researcher-made measures. Most of these measures included open-ended or multiple- choice comprehension questions. Some studies have also in- cluded measures of signal word identification and pre/post measures of text structure strategy knowledge.

Notably, none of the previous studies on the effects of explicit text structure instruction on text comprehension have included participants with DLD. Given the substan- tial gap in the literature and the evidence supporting the use of text structure instruction with adolescents with LD, the present case study examines the effectiveness of an explicit text structure intervention approach to treat expository reading comprehension difficulties in an adolescent whose etiology is linked to NS. This case study is presented to illus- trate the implementation of a text structure intervention program with an adolescent with language and learning dis- abilities associated etiologically with this rare congenital syndrome.

This Study Prior research provides evidence of the success of text

structure instruction for comprehension deficits among ado- lescents with and without LD. It is possible that text struc- ture intervention may also produce comprehension gains for adolescents with a history of DLD whose comprehension deficits have been otherwise difficult to remediate. The first step to examine a text structure approach to the treatment of reading comprehension problems is to establish the via- bility of the approach. We utilized a case study design with one baseline and one intervention phase (e.g., AB design) to determine whether explicit text structure instruction had

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a correlational relation with improvements in BD’s identifi- cation of signal words and comprehension of the compare- contrast text. With this design, it was feasible to document changes in the outcome data from the baseline to the inter- vention phase. Here, we present BD’s case to illustrate the practicability of a text structure intervention for expository text for an adolescent with language and literacy disabil- ities. The study was guided by the following research ques- tion: Will the implementation of an explicit text structure intervention result in improved identification of signal words for and comprehension of compare-contrast text?

Method Design

To address the research aim, we implemented a case study design with one baseline and one intervention phase (e.g., AB design). AB designs are efficient for feasibility studies to provide preliminary data regarding intervention effects. With an AB design, it is feasible to document changes in the outcome variable from the baseline to intervention phase and thus possible to determine whether a correlational relation exists between independent and dependent variables (Kazdin, 2010).

Participant The participant, referred to as BD, was recruited in

accordance with the procedures approved by the univer- sity’s Human Subjects Committee. BD was a Black male, age 14;6 (years; months) who was enrolled in the seventh grade. He participated in general education with weekly re- source support for reading and math as well as language therapy. His educational history was significant for grade retention. He had no history of hearing impairment, but his hearing was being monitored due to the increase risk with NS.

BD was referred to the intervention program at the university clinic by his mother due to concerns about his reading level and lack of progress with previous interven- tions. BD was initially diagnosed as a young child with de- velopmental disability, DLD, and speech impairment. He had been enrolled in speech-language therapy since the age of 18 months. He was later diagnosed with a reading- based learning disability (LD-R), epilepsy, narcolepsy, ex- ecutive function disorder, and a PTPN11 gene mutation, which is associated with Noonan’s syndrome. The latter diagnosis of NS was made by a geneticist and provided etiological insight for BD’s language, learning, and cogni- tive profile.

Initial Assessment Prior to entry in the text structure intervention pro-

gram, BD received an individualized language and literacy evaluation. His parent was interviewed for case history and referral information. The Student Language Scale was used to gather input from his parent about BD’s language and literacy skills. The parent completed a 7-point rating scale in which she rated BD’s language and literacy skills

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from 1 (not good) to 7 (very good) by circling a number to rate how good this student was at the named skill in com- parison to peers of the same age. This scale has been vali- dated as a screener for language/literacy disorder and to provide input for planning and other discussions between teachers, parents, and students. The lowest ratings (Level 1) were indicated for the items “Being organized about school- work,” “Paying attention in school,” and “Interacting so- cially with other students.” The highest ratings (Level 4) were for the items “Understanding school vocabulary words,” “Understanding a story when reading,” and “Writing a story that makes sense.” Remaining items (Level 3) included “Using school vocabulary words when talking,” “Figuring out new words when reading,” “Spelling words correctly when writing,” and “Following spoken directions.” The par- ent also identified areas easiest for BD were Art, Dance, and Music and his hardest areas were Math, Reading, and understanding social cues and adjusting behavior accordingly. The parent noted that their main goal was for BD to do bet- ter at school and learn how to read and comprehend better.

BD’s language and literacy skills were assessed with the Test of Integrated Language and Literacy Skills (TILLS; Nelson et al., 2016). The TILLS has been validated for asses- sing oral and written language in students ages 6 through 18 years for three purposes: (a) identifying language/literacy disorder; (b) describing patterns of strengths and weakness, and (c) tracking change over time (6-month periods or lon- ger). The TILLS has very good levels of sensitivity (86%) and specificity (90%). Specificity refers to the test’s accuracy with identifying children with a disorder, whereas sensitivity is the test’s accuracy of identifying children without a disor- der (Betz et al., 2013). Specificity and sensitivity are impor- tant psychometric properties of a norm-referenced test because they establish the precision with which a measure can differentiate typical from atypical language performance. The TILLS includes 15 subtests and yields several com- posite scores with a mean of 100 and standard deviation of 15. BD’s standard scores on the subtest composites fell three standard deviations below the mean: sound/word (40), sentence/discourse (41), oral composite (43), written Com- posite (40), identification core (40). These scores are con- sistent with a severe language/literacy disorder.

BD’s nonverbal intellectual ability was assessed with the Matrices subtest of the Kaufman Brief Intelligence Test, Second Edition (KBIT-2; Kaufman & Kaufman, 2004). The Matrices subtest of the KBIT-2 is a brief measure of non- verbal intelligence which measures the ability to perceive rela- tionships, complete visual analogies, think logically, and solve problems in novel situations. The KBIT-2 was admin- istered only for descriptive purposes and was not required for inclusion or exclusion criteria. Standard scores on the KBIT-2 have an M = 100 and an SD ± 15. His standard score of 90 fell within the average range.

Text Structure Intervention Program The text structure intervention (TSI) program used

in this study was developed by the first author to address

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reading comprehension deficits in school-age children and ado- lescents with DLD. Features of the program were selected and lessons developed based on prior evidence of effective components of text structure instruction, including evidence from two recent meta-analyses and one systematic review (Hall-Mills & Marante, 2020; Hebert et al., 2016; Pyle et al., 2017). The second author provided input on the design of les- son materials. The TSI design included six lessons focused on the compare-contrast type of expository text (describing simi- larities and differences between concepts or ideas). Compare- contrast was selected as the focal text structure because of its broad application in the middle school curriculum.

Each TSI lesson provided direct instruction regarding the purpose and characteristics of compare-contrast text, in- cluding vocabulary instruction on a range of signal words for compare-contrast text structure, discussion of the rela- tions among ideas that are framed by the signal words, modeling and guided practice identifying signal words and answering comprehension questions for a compare-contrast passage, followed by independent practice with another compare-contrast passage. Signal words are words within a passage that reflect the structure of the text and thus may increase coherence in support of comprehension (Hebert et al., 2016). Examples of compare-contrast signal words taught include “both,” “alike,” “difference,” “similar,” “have in common,” “as well as,” “as opposed to,” “on the other hand,” “options,” “whereas,” “although,” “however,” “in contrast,” “instead,” and “while.” Guided practice included think-aloud procedures in which the participant was peri- odically asked to comment about the text while reading and the interventionist probed comments by asking questions, modeling the answer, and providing support for inferential thinking (Laing & Kamhi, 2002).

Other researchers have suggested that comprehension intervention should build content knowledge by adhering to one genre or topic for a period of time (Elleman & Compton, 2017; Kamhi & Catts, 2017). Thus, we selected a thematic topic (“flight”) to focus the reading passage con- tent throughout the intervention. Baseline passages were not focused on this theme. For both the baseline and inter- vention phases, compare-contrast reading passages were sourced from a nonprofit resource of leveled reading mate- rial to measure signal word identification and comprehen- sion (ReadWorks, 2019). Passages were selected based on (a) adherence to the compare/contrast text structure, (b) in- clusion of three or more compare/contrast signal words, and (c) reading level consistent with passages selected for guided and independent practice. Passages selected for the intervention phase also were chosen based on their alignment with the thematic topic of flight. Reading passages were precalibrated for readability and grade level measures to ensure consistency (passages ranged 55–70 for the Flesch Reading Ease and 6.0–8.0 Flesch–Kincaid Grade Level). Science content was selected as the focus of the text structure instruction to provide ample opportunities to demonstrate comparative relations among concepts.

The TSI program included two measures to monitor BD’s progress with identifying compare-contrast signal

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words and answering comprehension questions. The same passage was used to measure the participant’s identification of signal words and accuracy with comprehension questions. The participant was instructed to review the reading passage and identify any helpful words about the purpose of the passage by circling them. This item was scored as the percent- age of compare-contrast signal words that were correctly identified. For example, if a passage included five compare- contrast signal words (e.g., different, but, however, though, while), and the participant identified three of them, then the accuracy of signal word identification was 60% (3/5). Each passage contained four to six compare-contrast signal words. Comprehension accuracy was measured with a 4-item probe developed for the same reading passage as for signal word identification. Comprehension question items were de- veloped by the first author and balanced by type to include the gist or main idea of the passage (e.g., what was the main idea of this passage?), text explicit information (e.g., what happens to a ball that you throw on Earth?), text implicit in- formation (e.g., why might it be a bad idea to sprinkle salt and pepper on your meal in space?), and structure implicit infor- mation (e.g., how is gravity different on Earth and in space?).

Assessment/Dependent Measures BD’s identification of compare-contrast signal words

and comprehension of compare-contrast text were measured in one combined probe. For this probe, a compare-contrast reading passage was provided to BD. The instructions for the dependent measures probe were scripted to ensure consistency of administration across probes. Instructions indicated that BD was to first identify any signal words in the passage by circling them with his pencil. Then he was instructed to read the passage aloud. We required him to read the passage aloud to keep him on task. Without this requirement, he would skip to answering the questions without reading the passage. He was not given any feedback during the passage read aloud. After completing his reading of the passage, he was instructed to review the comprehension questions and write his responses on the page. BD’s identification of signal words and responses to comprehension questions were double scored by a trained graduate research assistant for scoring reliability. The interobserver agreement level for both dependent measures was 100%.

Intervention After the baseline period, explicit text structure inter-

vention was provided during 60-min, twice weekly sessions over a three-week period. Each intervention session followed a similar structure. First, we provided direct instruction re- garding the purpose and characteristics of compare-contrast text, including vocabulary instruction on a range of signal words for compare-contrast text structure, and discussion of the relations among ideas that are framed by the signal words (10 min). BD was attentive during direct instruction prior to guided and independent practice portions of TSI lessons. Next, we provided modeling and guided practice identifying signal words and answering comprehension questions for a compare-contrast passage (25 min). After guided practice,

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the participant completed independent practice with a dif- ferent compare-contrast passage (20 min). Last, we reviewed the key concepts of the day’s lesson with reminders about the text structure strategy.

Guided practice included scaffolding (e.g., breaking task down into component parts, reviewing sentence-level signal words before returning to passage-level) and prompt- ing. Examples of prompting included the provision of verbal cues to remind BD to look for signal words that he had been taught previously, completion of a graphic organizer to review a passage, and verbal reminders to refer back to his notes with highlighted signal words and main idea state- ments. He also required prompting to remain on topic during lessons. He would draw information from previous experi- ences or background knowledge that would cause an off- topic conversation. Visual/graphic cues that were available in the treatment room included lists of signal words, exam- ples of completed graphic organizers, and illustrations of the compare-contrast text structure. For independent practice, verbal prompting was limited to general prompts about staying on task and providing encouragement for task completion. As task complexity and time to complete the task increased, BD benefitted from more frequent prompts to remain engaged. He also benefitted from occasional phys- ical breaks (e.g., to the restroom, snack break), a visual schedule, and interactive activities to maintain his attention. These behavioral observations are consistent with attention and executive function deficits that manifest in some indi- viduals with NS.

To ensure procedural integrity, a checklist was used by a trained research assistant who reviewed audio record- ings of 50% of the sessions. Baseline sessions were checked for inadvertent delivery of explicit text structure instruction or discussion of text structure strategies. For baseline ses- sions, there were no instances of explicit text structure instruction, including no instruction on signal words or compare-contrast text structure. The observer also completed treatment fidelity checks for 50% of the intervention sessions by reviewing video recordings. Intervention sessions were checked for consistency with the session outline, which in- cluded activities for explicit instruction regarding types of text, identification of signal words, and compare-contrast text comprehension. Across all observations each of the major components of text structure instruction (e.g., explicit instruc- tion, signal words, and comprehension tasks) were imple- mented consistently, thus establishing an adequate level of procedural integrity (100%). This method of observation- based measures of procedural integrity is consistent with prior research on text structure instruction (Williams et al., 2009, 2014).

Results The purpose of this case study was to implement text

structure intervention to improve expository reading com- prehension for an adolescent participant with NS and a history of DLD and LD in reading. The data were visually analyzed for level, trend, and variability to establish the

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specific nature of the changes observed. Stability of the base- line data was defined as limited variability in the dependent measure and no trend of improvement (Byiers et al., 2012; Kazdin, 2010). A stable baseline was achieved for both de- pendent measures prior to initiating the intervention, as shown in Figure 1. BD’s performance on the baseline probes reflected very low levels of accuracy. However, the effect was imme- diate for both signal words identification and accuracy of comprehension question responses with the initiation of the text structure intervention.

Signal Word Identification The participant’s progress over time was examined

via visual inspection of the data. Figure 1 reflects BD’s ac- curacy for identifying compare-contrast signal words and responding to comprehension questions. For signal word iden- tification, the data reflected a stable baseline trend. Prior to receiving explicit instruction with signal words, BD was unable to identify any signal words in compare-contrast texts. At the baseline, he highlighted words and phrases other than those involving signal words, and there were no detectable patterns in the words he selected. This indicated that BD did not appear to apply a specific strategy prior to reading that would assist him in identifying key words. His accuracy for signal word identification began to increase by the first probe after intervention was initiated and continued to improve steadily through subsequent probes in the intervention phase. BD’s final four probe scores during the intervention phase in- dicated that he was able to identify a majority of signal words in a compare-contrast passage.

As a measure of effect size, we calculated the percent- age of nonoverlapping data (PND), defined as the propor- tion of data points in the compare-contrast text structure condition that exceeded the highest value in the baseline phase (Campbell, 2003). PND values of 70%–90% are inter- preted as moderate and 90%–100% as strong support for treatment effectiveness (Meline, 2010). The PND for signal words identification was 100%, indicating strong support for the effectiveness of treatment. Finally, we supported the visual analysis with Tau-U effect size calculations using a free calculator from Single Case Research (n.d.). Tau-U

Figure 1. BD performance on dependent measures (sepa

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combines the nonoverlap between phases with trend from the intervention phase; Tau-U values of 0.93 or higher are interpreted as very effective (Parker et al., 2011). The Tau-U effect size of 1.00 for BD’s identification of signal words indi- cated strong effects.

Text Comprehension BD’s scores on the probes for comprehension question

accuracy are presented in Figure 1. Based on visual inspec- tion of the data, BD’s baseline data trend for comprehension question responses was stable, demonstrating a low level of accuracy in responses to comprehension questions after reading compare-contrast text. However, his accuracy in- creased throughout the intervention phase, resulting in a PND of 100%. Strong effects were indicated with a Tau U effect size of 1.00.

Discussion This study explored the feasibility of a text structure

intervention for an adolescent student diagnosed with NS, DLD, and LD-R. The results provided evidence of the posi- tive effects of text structure intervention on the participant’s text structure and signal word identification as well as compare-contrast text comprehension. It was observed that BD could not identify compare-contrast signal words prior to direct instruction using the structure strategy. He also had very low and inconsistent accuracy in answering comprehension questions after reading compare-contrast text. The systematic approach to learning about text struc- ture seemed to help BD learn how to recognize important signal words and comparative relationships in text and ap- ply that knowledge to reading tasks.

The results of this study contribute to the body of evi- dence in support of text structure intervention for reading comprehension deficits. These findings support those of Hebert et al. (2018) and Meyer et al. (2018) that it is feasible to focus on signal word identification as a comprehension aid. These findings also support the structure strategy’s role in compare-contrast text comprehension and align with find- ings of previous studies that focused on adolescents with

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LD (Gajria et al., 2007). The findings of this study are sim- ilar to those found by Nealy (2003), O’Connor et al. (2017), Wilkins (2007), and Meyer et al. (2010), who found that ex- plicit text structure instruction for compare-contrast text supported growth in expository reading comprehension of children with LD. Finally, given that most prior studies on TSI have focused on children without DLD, the results of this study have extended the current text structure strat- egy research to a clinical population at risk for protracted reading comprehension deficits.

Limitations and Directions for Further Research There are notable limitations to this study that war-

rant consideration. First, the generalizability of the results is limited because this was a case study focused on a single participant. Second, we cannot rule out factors beyond the intervention that might explain the changes in signal word identification and compare-contrast reading comprehen- sion. This is an artifact of an AB design. Our design did include two phases, including one baseline and one treat- ment phase. However, we cannot claim full experimental control with this design, and we cannot state with certainty that the improvements we observed in BD’s performance were not attributed to other factors we could not control for (e.g., maturation, history). While causal relations between the intervention and the outcomes cannot be drawn conclu- sively with the AB design, we can discern a correlational re- lation between the independent and dependent variables (Gast & Baekey, 2014; Kazdin, 2010). To improve upon these issues of research design, future studies should incor- porate additional phases (e.g., a maintenance phase) and more advanced quasi-experimental designs (e.g., multiple baseline across participants) to establish a functional rela- tion between the independent and dependent variables.

A third limitation is related to generalization of the text structure strategy to other text types. We did not mea- sure the participant’s comprehension of untaught expository text structures; hence, we do not know the extent to which he could have applied text structure strategy to other texts (e.g., cause–effect, problem–solution). Thus, we recommend that researchers and clinicians consider targeting and mea- suring a variety of text structures. Fourth, we did not include a measure of social validity within the present case. Social validity measures should be incorporated in future studies to help illuminate the participants’ perspectives on the useful- ness of the text structure strategy. Finally, alternative mea- sures of reading comprehension may reveal different effects. Further research should consider the full range of approaches to comprehension measurement, including the recall of idea units.

Clinical Implications Text structure intervention may provide adolescents

with a history of DLD and LD-R the tools to strategically use the text’s organizational and linguistic framework for better comprehension of expository text. Improvement of

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expository text comprehension is necessary for academic achievement in the later grades and presents an essential focal point of language intervention for adolescents. Our case study illustrates that a short-term, intensive treatment targeting compare-contrast signal words and text structure strategy for reading comprehension is feasible and effective for ado- lescents with DLD. These findings support and extend prior evidence, which has documented large effects for expository text comprehension for adolescents with LD after various periods of intervention. The text structure approach we used for comprehension intervention could be extended for addi- tional sessions and weeks, although BD achieved clinically significant gains in reading comprehension with a period of intervention lasting three weeks and with a total of 360 min of intervention. Other studies incorporating text structure instruction have provided various durations of intervention, from as few as 200 total minutes over the course of a few weeks to as many as 1,000 or more minutes across multiple weeks or months. With an extended duration, TSI may also be applied to other genres of text, including other types of expository text. Moreover, TSI could be part of a compre- hensive approach for targeting reading comprehension.

The study also illustrates that the format of the TSI lessons in this program was achievable in a twice weekly therapy schedule. We have established the practicability of text structure intervention in a clinical therapy model. How- ever, it will be important for future work to explore the feasibility of text structure instruction within language ther- apy sessions in a school setting. While we did not explore the practicality of TSI in a school context, we believe that text structure intervention can be incorporated in a school and group therapy setting. We believe this based on the tra- dition established in the literature to administer text struc- ture instruction to groups or whole classrooms. In a school context, clinicians would have the added benefit of direct collaboration with teachers on the authentic text and con- texts for the TS strategy, help with access to reading content, and support with progress monitoring in the classroom. Clinicians should consider using curricular materials, such as history or science texts, to increase their client’s back- ground knowledge for those specific content areas. Moreover, text structure intervention emphasizes the use of scaffolding and modeling with visual organizers. Nearly all of the prior text structure studies reviewed by Pyle et al. (2017) included scaffolding so that instruction was tailored to the indi- vidual. Thus, scaffolding should be a component of any text structure intervention. These strategies are particularly helpful for students with language learning difficulties simi- lar to BD. The results of our case study also indicate that text structure intervention can be effective while attending to the client’s needs for increased behavior, attention, and executive function management and scaffolding for comprehension.

Finally, this case illuminates the value and necessity of a comprehensive language and literacy assessment for an adolescent with NS. BD’s family had been in search of explanations for his reading comprehension difficulties. While we do not yet know all of the reasons for these challenges,

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we were able to document an updated language and literacy skills profile and monitor BD’s response to language inter- vention in a tightly controlled environment. Doing so under- scored the individual variability inherent in individuals with NS. Pierpont et al. (2010) found that 85% of children with NS had below average nonverbal skills commensurate with their language skills and most reflected language skills be- tween the mild impairment, average, and above average levels. In contrast to prior research detailing the language, literacy, and cognition of children with NS, BD had language skills that were profoundly impaired (i.e., standard scores on TILLS composites in the 40 s), and much lower than his nonverbal cognitive score, which was in the average range (i.e., SS = 90). In these ways, BD’s case was unique among children with NS in the sense that his diagnostic profile did not align with Pierpont et al.’s observation of syn- chronicity between cognitive and linguistic profiles among children with NS. Furthermore, despite the profound se- verity of his DLD, BD responded well to a short-term explicit text structure intervention and was able to learn how to identify compare-contrast signal words and in- crease his accuracy in responding to passage comprehen- sion questions.

In conclusion, this case study illustrates the value of a text structure approach to reading comprehension inter- vention for an adolescent with language and literacy deficits secondary to NS. Given the limited research in this area and the results of this case study, further research is needed to expand the evidence base for the use of explicit text struc- ture intervention for adolescents with language and learning difficulties.

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