Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks

Abstract

This initial study used an equivalent-groups design to evaluate differences in story comprehension scores between children with autism spectrum disorder (ASD) and their neurotypical (NT) peers using paper and iPad® storybooks. Fifteen children with ASD of ages 4–6 and 15 NT peers matched for receptive vocabulary age and gender met inclusion criteria. Across two individualized testing sessions, participants answered language abstraction questions about three formats of Pete the Cat stories (paper, iPad adult read, and iPad with the read-to-me feature activated) during shared storybook reading. When examining the entire group of participants, all children performed better with either type of iPad storybook compared to the paper book. The current study indicates storybooks on the iPad function in similar ways for NT children and children with ASD. Further, this research shows promise for using the iPad with young children during shared storybook reading. Directions for future research and implications for special education personnel are provided.

Keywords

tablets/iPad technology perspectives autism exceptionality literacy content/curriculum area

In the technologically driven 21st century, devices with screens including computers, smartphones, and tablets are more available in homes in the United States. When examining availability of technology in the home environment of young children, a 2017 survey of 1,454 American parents of children ages 0–8 revealed that 95% of parents have a smartphone in the home, 78% have a tablet, and 42% of children have their own mobile device (Rideout, 2017). Respondents represented all regions, diverse racial and ethnic backgrounds, and encompassed a range of income and educational levels.

Not only is technology readily available to young children at home but also in educational settings. Because of this availability and use of technology within preschool settings, the National Association for the Education of Young Children (NAEYC) and the Fred Rogers Center (2012) developed a position statement that suggested technology can enhance learning when used with adult guidance and developmentally appropriate practices. Although, without such guidance, technology can be detrimental to learning (NAEYC and Fred Rogers Center, 2012). A recent report indicated that of preschool teachers with access to tablets, 68% incorporated them regularly into classroom instruction (Pila et al., 2019).

With guidance, children need to become “technology handlers” to develop digital literacy similarly to becoming “book handlers” as a part of emergent literacy development (National Institute for Literacy, 2008). Further, several research studies and organizational policy statements have suggested parents and educators interact with children when using books on screen media devices as they would when reading a paper book (American Academy of Pediatrics, 2016; Lauricella et al., 2014; Office of Educational Technology, 2016; Strouse et al., 2013). When adults interact with children during shared reading of a book on a screen media device as they would with a paper book, the adults can confirm that the children comprehend the book (Office of Educational Technology, 2016). Participating in early reading experiences may be very different today than learning to read prior to the advent of personal tablet devices such as the iPad®.

Typically Developing Children and Books on Screens

Prior to the introduction of the iPad, van den Broek et al. (2009) stressed the use of e-storybooks on computers may decrease demands on decoding and may allow more cognitive resources to be available for comprehending a story. In addition, Robb (2010) indicated neurotypical (NT) children of ages 4 years, 6 months to 5 years, 6 months learned information equally well from a read-with-me DVD interactive book and a print book when asked to recall the story, sequence the story, or answer factual questions about the story.

Following the advent of the iPad, studies compared NT preschoolers’ storybook comprehension performance on paper and iPad books. The books have varied from researcher-created books in both formats (O’Toole & Kannass, 2018) to commercially available books from the Apple iBooks Store that align with the paper book (Reich et al., 2019; Richter & Courage, 2017). In these studies, iPad book conditions either have included multimedia features (sounds, animations, hot spots, highlighting text, etc.; Bus et al., 2015; Reich et al., 2019; Richter & Courage, 2017) or have not (O’Toole & Kannass, 2018).

Of the studies and reviews conducted with young children using books on iPads® with multimedia features (Bus et al., 2015; Reich et al., 2019; Richter & Courage, 2017), story comprehension measures and results have varied. When reviewing research exploring children’s interactions with books on screen devices (including phones, tablets, and e-readers) with multimedia features, Bus et al. (2015) concluded that including only sounds, images, and animations semantically related to the story line were beneficial. Further, these researchers found children participate in multitasking when presented with books on screen devices with multimedia features, which include features such as animations or sounds unrelated to the story line. Multimedia features such as these could cause children to process visual and auditory input separately rather than simultaneously which could lead to “cognitive overload” (p. 82).

In a study of books on screens with multimedia features, Richter and Courage (2017) compared paper books to books on an iPad using the read-to-me feature. These researchers analyzed 79 Canadian NT preschoolers’ engagement, attention, and recall. The stories in the two formats were similar in length, written by the same children’s storybook author, and included an animal character. The iPad book revealed one page at a time and all animations and sound effects were related to the story line. In measuring recall, the authors asked nine (five fact-retrieval and four inference) questions. Results revealed no significant difference in children’s recall of the story between the two book formats.

Recently, Reich et al. (2019) studied preschool children’s engagement, story comprehension, and vocabulary between a paper book and an iPad book with both hot spots (i.e., when tapped display animation or repeat words) and the read-to-me feature. Children had slightly higher story comprehension and vocabulary scores with the paper book. Engagement was equal with both book formats. These researchers did not examine the use of an iPad alone (i.e., without hot spots or the read-to-me feature).

With these advances in research for typically developing children, there is a developing corpus of research indicating how books on screen media devices support a diverse population of children. However, the body of research evaluating books on screens for children with a diagnosed disability is limited (Moody & Swafford, 2019). Children with a diagnosis of autism spectrum disorder (ASD) may be particularly interested in books on screen media devices.

Children With ASD and the Advantages of Screens

Zenko (2014) indicated children with ASD display a relative strength in processing visual stimuli and using visual information. Additionally, research has demonstrated visual aspects of technology align with the visual processing strengths of children with ASD (Shane & Albert, 2008). Given these visual processing strengths, many educational professionals are using screen media devices such as the iPad for a variety of purposes including assessment. For example, in a study of young children with ASD comparing paper and iPad versions of a receptive vocabulary test, Marble-Flint et al. (2019) found that scores were similar on both versions of the test.

Furthermore, a fascination with electronics and the ability to ignore distractions while engaged in electronic media (Shane & Albert, 2008) have been cited as influencing factors for selecting the iPad as an educational tool. This fascination allows children with ASD to readily interact with the iPad and other iOS devices without (or with very little) instruction relative to their operating features (Caron & Shane, 2014), but few empirical studies in this area exist.

Since 2009, The National Autism Center has been conducting phases of systematic reviews of peer-reviewed research of educational and behavioral interventions used with individuals with autism. Phase 1 was a review of studies published from 1957 to 2007 with individuals with autism under the age of 22. This review was compiled into the National Standards Project Report Phase 1 (2009). The report indicated technology-based interventions have been effective for improving academic, communication, personal responsibility, and self-regulation skills in children with autism of ages 6–14. At the time of the report, no studies included children younger than 6 years. The Center’s Phase 2 Report (2015) from a systematic review of peer-reviewed intervention research for children, adolescents, and adults (above the age of 22) with autism from 2007 to February 2012 demonstrated technology interventions are “emerging” rather than “established” treatment approaches. The Center did not detail information for “emerging” treatment approaches, only “established” ones. Under the National Autism Center’s criteria, emerging treatments might be advantageous, and further research is needed to confirm such outcomes. Phase 3 is scheduled to release in 2021 with a review of studies conducted through 2018 (National Autism Center, 2020).

As noted in a recent meta-analysis, researchers have studied the use of iPads for academic interventions, including literacy, for children with ASD in kindergarten through 12th grade (Larwin & Aspiranti, 2019). Further, when examining literacy skills and story comprehension of iPad books for individuals with ASD, much of the available research has been conducted with school-age children, adolescents, or adults in transition services (Alison et al., 2017; Price, 2011).

In most studies determining differences in story comprehension using iPad formats of books, answers to questions have been scored as either right or wrong. Other approaches to asking questions might be more developmentally sensitive. In the current study, levels of abstract reasoning questions were used, which are described next.

One hierarchical approach using levels of language abstraction was developed by Blank et al. (1978, 2003). These authors created the Preschool Language Assessment Inventory, which requires children to answer questions from four levels of increasing complexity: matching, selective analysis, reordering, and reasoning. The levels follow a developmental progression of abstract reasoning beginning in the preschool years, and children are expected to answer questions at all four levels by age 6. Different levels of abstraction indicate the distance that language is from the topic being examined (Westby, 2007).

The first level of questions (Level 1) is matching. The language to answer the questions is found by looking at pictures in the book such as (“Where is the flower?”) when the flower is closely pictured. Selective analysis (Level 2) questions require prior knowledge from experiences and ask about less obvious features of objects such as attributes (e.g., “What color can apples be?”). The next level, reordering of perception (Level 3) involves using discernment about objects and experiences. A sample question from Level 3 may include negative terms such as (“Which one is not something you wear?”). Finally, reasoning about perception (Level 4) expects the child to use abstract thinking skills. The “why” questions are at Level 4, including those requiring justification of information (“Why does everyone want a painting?”). All four are Wh-questions; however, the levels of abstraction are quite different.

Purpose

The use of tablet technology, including the iPad^®, for shared storybook reading with children with ASD is not widely researched (Ennis-Cole, 2015). A recent meta-analysis of the use of the iPad for academic purposes with children with ASD indicated that currently available studies have examined a wide range of skills and participant characteristics, which makes it difficult to draw conclusions (Larwin & Aspiranti, 2019). Further, there is limited information about the way young children, both NT and children with ASD, answer language abstraction questions about storybooks. This study aimed to determine differences between three methods of storybook formats with two levels of abstraction questions to test the format of the book and the way children comprehended information about the story. These two levels of abstraction were utilized to verify testing was done of the format of the stories rather than evaluating the children’s capabilities of answering questions of varying levels of abstraction.

Therefore, the purpose of this study was to investigate potential differences between paper and iPad presentation of storybooks through answering the following questions: (a) Is there a difference in story comprehension scores when children in both groups (the entire study sample) are read to with a different book format (iPad book with the read-to-me feature activated, iPad book read by the first author, and a paper book)? (b) Are there differences in story comprehension scores between children in the two groups, ASD and NT peers? (c) Does an interaction exist between the book format and participant group? (Is there a difference in how children in different groups responded to comprehension questions with varying formats of storybooks [iPad book with the read-to-me feature activated, iPad book read by the first author, and a paper book])? The authors hypothesized that children in both groups would perform the best using the iPad book with the read-to-me feature activated. In addition, it was expected that children with ASD would perform as well as outperform their typically developing peers because of their visual strengths and understanding of the iPad’s features (Caron & Shane, 2014; Shane & Albert, 2008; Zenko, 2014).

Method

Research Design

This study used an experimental equivalent-groups design to examine differences between story comprehension scores using paper and iPad books. The following three storybook formats were compared: paper storybook reading by an adult, iPad storybook reading by an adult, and a read-to-me feature on an iPad.

Participants

A total of 37 children were recruited for this study. Community advocacy groups, school districts, and a university speech-language clinic in a Midwestern metropolitan area served as recruitment sites for the participants with ASD. Flyers were posted and/or distributed at these sites with the first author’s contact information. In addition, parents of children who were identified with autism through participation in an interprofessional diagnostic team at the university speech-language clinic were contacted by the first author. NT participants were recruited through word of mouth, flyers, families associated with the university speech-language clinic in the Midwestern metropolitan area, and families associated with the university childcare center.

Parents of potential participants completed a phone interview with the first author prior to testing sessions to determine their child’s eligibility for the study. Further, parents/guardians signed an informed consent document approved by the institutional review board. Seven participants did not meet eligibility criteria. Therefore, participants included 30 children, 15 diagnosed with ASD whose chronological ages ranged from 4 years, 0 months to 6 years, 11 months (M_age = 5.58 years, standard deviation [SD] = 1.07) and 15 NT receptive vocabulary-age-matched peers (M_age = 4.36 years, SD = 1.03). Six participants (3 with ASD and 3 NT) were female and 24 (12 with ASD and 12 NT) were male. Of the participants with ASD, 10 were White, 2 were Black/African American, and 3 were multiracial. In the NT group, 13 were White, 1 was Asian, and 1 Other. Participants were located within an approximate 20-mile radius to the urban, Midwestern university speech-language clinic and used their own means of transportation to attend research sessions. Participants’ families from both groups received a US$10 gift card for the first testing session and an additional US$10 gift card following the second testing session to encourage continued participation and acknowledge their time commitment.

Participants with ASD

Fifteen participants met eligibility requirements, which included medical diagnosis of autism, vision and hearing within normal limits, English-speaking (not learning English as a second language), communicating verbally without the use of an augmentative alternative communication (AAC) device, ability to independently attend to stimuli on an iPad device and paper storybook, and receptive vocabulary score ±1.5 SD from the mean. Medical diagnosis was reported by parents, teachers, and/or other educational professionals and confirmed through school (individualized education program or multidisciplinary team report) and/or medical record (diagnosis provided by developmental pediatrician or clinical psychologist). Either parent confirmation of passed vision and hearing screening or record review confirmed participants’ eligibility.

Participants with NT development

Fifteen NT participants were matched to the ASD participants for gender and receptive vocabulary age (±6 months). Children diagnosed with a developmental disability or speech-language disorder were not included.

Measures

Peabody picture vocabulary test

The first author, a licensed speech-language pathologist, administered the paper version of the Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4; Dunn & Dunn, 2007a). There is a newer edition currently available; however, this updated version was not published when testing began. Research has shown that receptive vocabulary skills are related to “general verbal ability” (Dunn & Dunn, 2007b, p. 1). Additionally, vocabulary development may be considered a gauge for a child’s cognitive and social development. For preschoolers, vocabulary skills can be an indication of school readiness (Dunn & Dunn, 2007b). To match participants with ASD to NT participants, the children’s vocabulary-age-equivalent scores on the PPVT were used. For inclusion in the study, all participants achieved a receptive vocabulary standard score ±1.5 SD from the mean. Means and SDs for PPVT standard scores for the two groups were as follows: NT (M = 113.87, SD = 10.40) and ASD (M = 100.07, SD = 13.74).

Hierarchy of language abstraction questions

The first and second authors used a hierarchy of language abstraction (Blank et al., 2003) to develop story comprehension questions. The four levels of increasing complexity of language abstraction include the following: matching, selective analysis, reordering, and reasoning. In the current study, only the first two levels were used to eliminate the influence of the content of the questions on the participants’ responses and to assure the study was comparing the format of the storybooks rather than the participants’ abilities to answer questions. Further, ranking answers to questions on a scale rather than simply marking correct or incorrect permitted participants to earn points for answers they gave that were close, but not fully correct. Table 1 lists scoring guidelines of a sample question.

Table 1.
Sample Question and Scoring Guidelines.

Guideline Example Question“What Is This?”(Answer: Baseball) Score Description Numerical Rating

Response is completely correct Baseball Fully adequate 3

Response is correct but poorly expressed and/or includes extra information Softball Acceptable 2

Response is unclear whether it is correct or incorrect Throw it Ambiguous 1

Response is not correct or no response was given Game Inadequate 0

Note. Adapted from Blank et al. (2003).

A pilot study was conducted using the paper format of the three books from the current study to determine the validity of the questions and whether the questions elicited an appropriate range of responses with a group of 15 NT children (not in the current study). Results of this pilot study were used to develop a scoring rubric that was adapted from Blank et al. (2003) to evaluate the participants’ responses.

Language screener

A 10-question language comprehension screener modified from the Preschool Language Assessment Inventory (PLAI-2; Blank et al., 2003) verified the participant’s ability to answer Level 1 and Level 2 questions. Although the PLAI-2 (Blank et al., 2003) has four levels of abstraction (least to most abstract), the language comprehension screener only included Level 1 and Level 2 questions. Level 3 and Level 4 questions were not included to assure that the research team was measuring differences between storybook formats not the participants’ ability to answer the questions. In addition, Levels 3 and 4 include aspects related to understanding characters’ perspectives and motivations, which may be difficult for the children in this study. These types of questions are beyond the scope of the present study.

As shown in Table 1, scoring of the language comprehension screener was done using the ratings from the PLAI-2, which include fully adequate, acceptable, ambiguous, and inadequate. A criterion score on the language screener of 80% correct as an acceptable rating on Level 1 questions and 60% correct as an acceptable rating on Level 2 questions was required for participants’ inclusion in the study. The rationale for these criterion score levels was aligned with the PLAI-2 scoring manual instructions, which indicate that when a child’s percentage of accuracy falls below 70%, more information is needed to understand why the child is having difficulty with that type of question (Blank et al., 2003, p. 18). Therefore, for inclusion in the study, participants’ accuracy of responses for Level 1 questions on the language screener was required above the criterion level of 70% set by the authors of the PLAI-2. Since Level 2 questions require a higher level of language abstraction, a criterion score of 60% was set for these questions on the language screening. Further, a criterion score of 60% assured that the participants’ percentages of accuracy were at more than a “chance” percentage (i.e., 50%).

Procedure

For all participants, two individualized research sessions lasting approximately 1 hr in total including breaks were completed at the university’s speech-language clinic and were video-recorded using a Sony Handycam™ HDR-CX405 HD flash memory camcorder. The first session determined a participant’s eligibility for the study. The eligibility testing included an assessment of receptive vocabulary, using the paper version of the PPVT-4 (Dunn & Dunn, 2007a) and the language screener. If a participant qualified for the study following this eligibility testing, the participant engaged in shared reading of one storybook and answered questions during the first session. To control for order effect, the first author randomized the order of book presentation. During the second session, the participant was involved in shared storybook reading using the two books not read on the first day based on the randomized order.

Materials

Storybooks

The I Can Read™ collection of children’s storybooks includes a leveled system ranging from My Very First to Advanced Reading (Harper Collins, 2019). In the present study, all books were selected from the Shared Reading level, which is designed for shared storybook reading with emergent readers. Further, all books were at a Flesch-Kincaid grade level of 2.4 and below and at a Lexile level of 420 and below. Lexile levels account for both word frequency and sentence complexity (Doman, 2019; Swanson & Wexler, 2016).

Pete the Cat, one popular children’s storybook series within the I Can Read™ collection highlights the main character, a cat named Pete, experiencing events highly relatable to younger children. Previous research using Pete the Cat books indicated featuring Pete as an animal rather than a child eliminated influences of gender, culture, and ethnicity; furthermore, the basic language and word repetition within these books was beneficial to children with ASD (Lee, 2013).

Three Pete the Cat books with various formats were used including paper book, iPad book read by the first author, and iPad book with the read-to-me feature activated. The selected titles were 32 pages in length and available for purchase in both a paper format and an iPad format via the iBooks app. iPad book formats were displayed on an Apple iPad Air 2. In addition, both iPad storybook formats displayed two pages simultaneously, emulating the paper book.

Storybook reading protocol

The paper book Pete the Cat and the Bad Banana (Dean, 2014a) was read by the first author, beginning with reading the title and author, followed by text on page one. When reading this book, the first author used a similar rate and intonation as the iPad book with the read-to-me feature. In advance, the first author wrote the 10 questions on sticky notes and individually affixed them to the page on which the question was asked. Writing the questions in advance and embedding them in the story increased reliability (van Kleeck, 2008; van Kleeck et al., 2006). During reading, the first author asked the questions and coded the participant’s response (see Online Appendix A for the list of paper book questions). After the first author recorded the response, the participant turned the page and the procedure was repeated throughout the book. If the participant did not turn the page, the first author said, “Let’s see what happens next.” After this prompt, if the participant still did not turn the page, the first author turned the page and continued reading.

The story Pete the Cat: Too Cool for School (Dean, 2014b) was displayed on the iPad Air 2 for the adult read format. In this iPad book format, the read-aloud feature was turned off and the first author read the story. The turn-my-page feature was deactivated. Turning off this feature requires the page to be “swiped” for the next double page to appear and reading to continue. During the reading of this iPad book format, procedures and scoring mirrored that of the paper book reading with the first author asking questions from a list rather than the sticky notes. The list indicated the page number corresponding to each question to assure the questions were asked in the same place each time (see Online Appendix B for the list of the iPad adult read questions).

Finally, for the iPad read-to-me book format, Pete the Cat: Pete at the Beach (Dean, 2013) was shown on the iPad with the read-to-me feature activated and turn-my-page deactivated. The read-to-me feature read the book to the child with a prerecorded voice within the iBooks app and highlighted the words blue as they were read. In addition, there were sound effects on select pages of the story related to the story line (e.g., eating and drinking sounds when Pete the Cat and his mother had a picnic). This version did not include hot spots. The same procedure was followed as the adult read iPad condition (see Online Appendix C for the list of the iPad read-to-me questions).

Procedures to facilitate participant motivation

Participants had two 5-minute breaks during each testing session to engage in free play apart from the author-directed activities. The participants selected from a variety of activities including both table (e.g., puzzles and cling-on sticker scenes [e.g., farm scene, construction site scene, etc.]) and gross motor activities (e.g., popping bubbles, riding a scooter).

Further, work systems (Hume et al., 2009) were used during both sessions with both groups to assist participants in understanding what tasks would be completed, how many tasks would be completed, and when the participants would be finished (Hume & Reynolds, 2010). The work system was structured in a left-to-right fashion with tasks contained in plastic bins. In addition, a Velcro strip that contained visual icons matching the plastic bins and icons indicating breaks was used to further assist participants in knowing the order of study activities. After work tasks and break activities were completed, the child placed the materials in the finished basket. If the participant demonstrated difficulty transitioning between study activities, the first author reduced the number of visual icons to two icons using a “first-then” visual (Hume, 2008). Upon removal of all visual icons, the child received a preferred snack reinforcer.

Rater Training and Reliability

To avoid detection bias, two graduate students who were naive to the purpose of the study were trained by the first author to independently rate participants’ responses after watching the video recording. Training was done using sample questions from the pilot study until consensus was reached on all acceptable and ambiguous ratings. The responses were scored as fully adequate (3 points), acceptable (2 points), ambiguous (1 point), or inadequate (0 points); (Blank et al., 2003); see Table 1 for sample question and scoring). There was a maximum of 30 points.

Intraclass correlation (ICC) reliability was calculated using total scores from 86% of the participants on each of the three storybook formats. Model 3 ICCs were run to determine interrater reliability among the three raters (the first author and the two trained graduate students). This type of ICC was chosen because each participant was assessed by all three raters. In addition, the raters were not randomly selected. The ICC found a high degree of reliability between the three raters when rating comprehension scores for the children with ASD, and the average measure ICC was .95 with a 95% confidence interval from .83 to .98, F(38, 76) = 31.72, p =.00. A high degree of reliability was also found from the ICC when rating comprehension scores for the NT peers. The average measure ICC was .96 with a 95% confidence interval from .86 to .98, F(38, 76) = 46.91, p = .00. ICC coefficients close to 1 indicate excellent interrater reliability has been achieved.

Results

All three raters scored answers to the story comprehension questions from the three different storybook formats (iPad book with the read-to-me feature activated, iPad book read by the first author, and paper book). The mean scores of the three raters were used for statistical analysis.

Statistical analyses were conducted using IBM SPSS Statistics Version 24 predictive analysis software. A two-way, 2 (group: NT and ASD) × 3 (comprehension scores for each format: iPad book with the read-to-me feature activated, iPad book adult read, and paper book), repeated measures multivariate analysis of variance was conducted. Participant group was the independent variable and scores on the three book formats were the dependent variables. There was a significant main effect for book format, F(2, 27) = 4.53, p < .05, Wilks’ L = .749, η² = .25 (see Table 2 for descriptive statistics).

Table 2.
Descriptive Statistics of a Two-Way Repeated Measures MANOVA for Group and Comprehension Scores.

Storybook Format Group M SD N

iPad® read-to-me NT 25.73 4.33 15

ASD 23.69 4.66 15

Total 24.71 4.54 30

iPad adult read NT 26.64 2.51 15

ASD 24.16 3.89 15

Total 25.40 3.46 30

Paper NT 23.82 4.21 15

ASD 21.87 5.78 15

Total 22.84 5.07 30

Note. ASD = autism spectrum disorder; NT = neurotypical; MANOVA = multivariate analysis of variance.

Because there were three storybook formats, a post hoc test with Bonferroni correction was conducted to determine exactly which means were significantly different in the main effect for format. Results indicated that with all children included, all performed significantly better with either form of iPad. iPad read-to-me versus paper, t(29) = 2.09, p < .05, and iPad read by an adult versus paper, t(29) = 3.09, p < .01. In addition, results of the post hoc paired samples t test are shown in Table 3.

Table 3.
Comprehension Scores Post Hoc Paired Samples t Test.

Pair Storybook Format t df Significance (two-tailed)

1 iPad read-to-me—Paper −2.09 29 .05

2 iPad read-to-me—iPad—Adult read 0.86 29 .40

3 iPad adult read—Paper −3.09 29 .01

Note. n = 30.

There was no significant main effect for group, F(1, 28) = 3.05, p = .09. Further, there was no interaction between group and book format, F(2, 27) = 0.06, p = .94. This indicates that overall, the two groups of children comprehended the books in similar ways. Figure 1 shows the interaction effect between format of book reading and group was not statistically significant.

Figure 1.
Means of story comprehension scores in children with autism spectrum disorder and their peers across three storybook modalities.

Discussion

The purpose of this study was to examine differences in story comprehension scores between children with ASD and their NT peers using paper and two iPad storybook formats. The results of this study add to the growing corpus of literature comparing screen media books, including those using the read-to-me feature, to paper books when used with young children (Bus et al., 2015; Reich et al., 2019; Richter & Courage, 2017).

Throughout all three book formats, an adult interaction component was used as the first author asked the participants questions. This adult interaction component aligns with information from the NAEYC and the Fred Rogers Center (2012) and the American Academy of Pediatrics (2016) suggesting children engage with others during screen media use so they are not passively viewing the media on the screen.

All participants performed better with the iPad book formats as compared to being read a paper book. These results contrasted with the existing research investigating NT children’s comprehension of iPad and paper books. For example, Richter and Courage (2017) found no significant difference in recall of stories between iPad books using the read-to-me feature and paper books. In the Richter and Courage study, when participants were asked questions, if they did not know the answer, response options were provided. From there, participants were awarded 1 point for correct responses and 0 points for incorrect responses. However, in the present study, the comprehension questions were developed using a hierarchy of abstraction and scored with a graduated scale of correctness. It is possible that this difference in scoring accounts for the difference in results between the current study and the work of Richter and Courage.

In the current study, the iPad read-to-me format itself aligns with previous research by Bus et al. (2015) which indicated sound effects and other features of e-books on screen devices are beneficial when they parallel the text of the story. With the read-to-me version of the iPad story used in the current study, the words were highlighted blue as a prerecorded voice within the iBooks app read the story. Additionally, there were sound effects on select pages of the story related to the story line (e.g., eating and drinking sounds when Pete the Cat and his mother had a picnic). However, there is little empirical evidence investigating the way children answer questions about books on the iPad with and without the read-to-me feature compared to paper books as was done in the current study.

Limited research exists which has examined the use of the iPad and special populations of children including children with ASD (Ennis-Cole, 2015; Moody & Swafford, 2019). No known research has been conducted comparing the story comprehension skills of young children with ASD and NT children with the read-to-me feature on the iPad or the iPad alone prior to the current study. Therefore, this study provides early empirical evidence that there is not a difference between the way these two groups of young children answer questions about storybooks in either iPad or paper formats. Further, this study offers information when beginning to examine different features on the iPad and the use of a scoring tool with a graduated level of correctness.

Implications

To promote active participation, the authors used story comprehension questions modeled after Blank et al. (2003) throughout the storybook readings rather than at the end of the stories. Educational professionals may consider the following when reading storybooks, no matter the format of the story: using questions of various language abstraction levels, asking the questions throughout the stories to promote children’s active participation, and scoring questions with a graduated scale of correctness rather than scoring correct/incorrect.

In developing the current study, the authors selected iPad stories without extraneous sound effects or animation unrelated to the story, aligning with previous research by Bus et al. (2015). Further, during data collection with both iPad stories, the turn-my-page feature was deactivated to allow the child to turn the pages in the story and to permit natural pauses for asking questions. Professionals and parents should consider adjusting such features of an iPad book in advance of reading to children.

Overall, storybooks displayed on the iPad may be beneficial to both children with ASD and children who are NT. Classroom teachers, special educators, reading specialists, and speech-language pathologists may consider the use of iPad storybooks if the students have previously responded positively to the iPad for other purposes. In addition, professionals should consider allowing children to make choices about which storybook format they would prefer since each format may be as effective.

Limitations and Future Directions

There is much more to explore regarding the way children respond to questions after engaging in shared storybook reading with different formats of books. A limitation to the current study was the small sample size. Given the eligibility requirements for participants with autism to be verbal, pass a language screening, and score no more than 1½ SDs below the mean on the PPVT, the pool of possible participants for the study was narrow. It is unknown how participants not meeting the study requirements would perform on iPad tasks, particularly children who are not verbal, but who could complete a test of vocabulary comprehension and answer questions about storybooks.

A second limitation was the lack of assessment of children’s experience with the iPad and other screen media devices prior to data collection. A current study interviewed parents of NT children about frequency of tablet use and reading on screen media devices prior to their study comparing comprehension performance on iPad and paper books. The researchers also found that novelty of book format may have an impact on children’s story comprehension scores (Reich et al., 2019). Future studies evaluating story comprehension of young children with ASD and NT children using paper and iPad book formats should assess prior experiences with both formats to determine the relationship between experience and children’s comprehension scores.

This area of research remains a “young science” (Ennis-Cole, 2015), and while there are several possibilities for future studies, the authors have identified two primary areas. With the small sample size in the current study, and the dearth of research in the area of story comprehension using iPad book presentations, it would be beneficial to expand this study to include more participants. Future studies may broaden the participant sample by investigating how children with autism using an AAC device would score on story comprehension questions when a book is presented on the iPad. Finally, future studies could investigate using Level 3 (reordering of perception) and Level 4 questions (reasoning about perception) to measure language abstraction and inferencing abilities in children with ASD. The current study focused on abstraction questions at a developmentally lower level to examine the book formats rather than the participants’ language abstraction abilities.

Conclusion

This research shows promise for the use of screen media, the iPad, in particular, for storybook reading and comprehension. Further, it adds to the evidence in technology use for children with ASD, supporting the National Autism Center’s (2009, 2015) recommendation that additional research is needed to confirm technology-based interventions are advantageous. With the ever-changing nature of screen media, it is vital for researchers and educational professionals to continue to evaluate the use of technology for book reading.

Supplemental Material

Supplemental Material, sj-pdf-1-jst-10.1177_0162643420924197 – Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks

Supplemental Material, sj-pdf-1-jst-10.1177_0162643420924197 for Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks by Karissa J. Marble-Flint, Kathy H. Strattman and Marlene A. Schommer-Aikins in Journal of Special Education Technology

Supplemental Material

Supplemental Material, sj-pdf-2-jst-10.1177_0162643420924197 – Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks

Supplemental Material, sj-pdf-2-jst-10.1177_0162643420924197 for Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks by Karissa J. Marble-Flint, Kathy H. Strattman and Marlene A. Schommer-Aikins in Journal of Special Education Technology

Supplemental Material

Supplemental Material, sj-pdf-3-jst-10.1177_0162643420924197 – Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks

Supplemental Material, sj-pdf-3-jst-10.1177_0162643420924197 for Comprehension Scores Among Young Neurotypical Children and Children With Autism: Paper and iPad® Storybooks by Karissa J. Marble-Flint, Kathy H. Strattman and Marlene A. Schommer-Aikins in Journal of Special Education Technology

Guideline	Example Question“What Is This?”(Answer: Baseball)	Score Description	Numerical Rating
Response is completely correct	Baseball	Fully adequate	3
Response is correct but poorly expressed and/or includes extra information	Softball	Acceptable	2
Response is unclear whether it is correct or incorrect	Throw it	Ambiguous	1
Response is not correct or no response was given	Game	Inadequate	0

Storybook Format	Group	M	SD	N
iPad® read-to-me	NT	25.73	4.33	15
ASD	23.69	4.66	15
Total	24.71	4.54	30
iPad adult read	NT	26.64	2.51	15
ASD	24.16	3.89	15
Total	25.40	3.46	30
Paper	NT	23.82	4.21	15
ASD	21.87	5.78	15
Total	22.84	5.07	30

Pair	Storybook Format	t	df	Significance (two-tailed)
1	iPad read-to-me—Paper	−2.09	29	.05
2	iPad read-to-me—iPad—Adult read	0.86	29	.40
3	iPad adult read—Paper	−3.09	29	.01

Footnotes

Acknowledgments

The authors would like to extend appreciation to the committee of faculty who supported this work and the graduate students for their assistance, especially Lydia McIntee whose work was instrumental with the final draft of this article. Special thanks to the families whose children participated in this research project.

Authors’ Note

Initially, this project began as part of the first author’s doctoral dissertation, and preliminary results were presented at the American Speech-Language-Hearing Association Convention in 2017.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: This work was supported by grant funding through the Clifford W. and Leah E. Gaulter Memorial Grant from the College of Health Professions at Wichita State University.

ORCID iD

Karissa J. Marble-Flint

Supplemental Material

The supplemental material for this article is available online.

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