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Story stem narratives with young

children: Moving to clinical research
and practice
a
Joann L. Robinson
a
University of Connecticut , Storrs, USA
Published online: 04 Dec 2007.

To cite this article: Joann L. Robinson (2007) Story stem narratives with young children: Moving
to clinical research and practice, Attachment & Human Development, 9:3, 179-185, DOI:
10.1080/14616730701453697

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 Attachment & Human Development,
September 2007; 9(3): 179 – 185

Story stem narratives with young children: Moving to

clinical research and practice
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JOANN L. ROBINSON

University of Connecticut, Storrs, USA

Abstract
Story stem narrative methods have demonstrated reliability and validity as assessments of the young
child’s representations of parent – child and peer relationships. Most, but not all, prior research has
been conducted with samples of typically developing children. Growing interest in the method from
clinical researchers and child psychiatry clinics brings forward a number of critical issues in its use
with children referred for severe behavioural disruption and mood disorder. This special issue of
Attachment & Human Development provides a collection of papers that demonstrates some of the
unique theoretical contributions of the method for clinical research. Practical aspects of using story
stem methods with the referred child are also considered.

Keywords: Story stem narratives, assessment, clinical methods, young children, attachment processes

Story stem narratives are coming of age as a reliable and valid assessment method that
permits us to inquire of the young child about how they think and feel about important
relationships. Story stem approaches to observing the typically developing young child’s
representations of family life have made significant contributions to attachment theory
(e.g., Bretherton, Ridgeway, & Cassidy, 1990; Green, Stanley, Smith, & Goldwyn, 2000;
Oppenheim & Waters, 1995; Steele et al., 2003; Verschueren, Marcoen, & Schoefs, 1996)
early moral internalization (e.g., Buchsbaum & Emde, 1990; Emde, 1994; Oppenheim,
Emde, Hasson, & Warren, 1997), and processes associated with child behavior regulation
within the family (e.g., Grych, Wachsmuth-Schlaefer, & Klockow, 2002; Oppenheim,
Emde, & Warren, 1997; Zahn-Waxler, Cole, Richardson, Friedman, Michel, & Belouad,
1994). Story stem approaches have also addressed similar questions within samples of
African American children (Robinson & Eltz, 2004), children in non-US cultures (e.g.,
Sher-Censor & Oppenheim, 2004; Shin, Lee, & Lee, 1999; Steele et al., 2003; von
Klitzing & Burgin, 2005), and children who have experienced disrupted or violent atypical
family experiences (e.g., Page & Bretherton, 2001; Toth, Cicchetti, Macfie, & Emde, 1997).
Studies have incorporated story stems in investigations of interventions with families: one
with demographic risks for maltreatment (Olds et al., 2004; Robinson, Herot, Haynes, &
Mantz-Simmons, 1999) and one with maltreated children (Toth, Maughan, Manly,
Spagnola, & Cicchetti, 2002). While numerous papers have provided evidence for reliable

Correspondence: JoAnn Robinson, Department of Human Development and Family Studies, University of Connecticut, 348
Mansfield Rd, Storrs, CT 06269-2058, USA. Tel: 860 486 8781. Fax: 860 486 3452. E-mail: JoAnn.Robinson@UConn.edu

ISSN 1461-6734 print/ISSN 1469-2988 online Ó 2007 Taylor & Francis

DOI: 10.1080/14616730701453697
 180 J. L. Robinson

correlations between story stem responses and symptom reports (e.g., Warren, Emde, &
Sroufe, 2000; Warren, Oppenheim, & Emde, 1996), until very recently, few studies inves-
tigated psychopathology using the story stem method within samples of children who have
been referred for specific emotional and behavioral disturbance. Greenberg, DeKlyen,
Speltz, and Endriga (1997) and the research from the Mount Hope Center at the University
of Rochester (e.g., Macfie, Cicchetti, & Toth, 2001; Toth, Cicchetti, Macfie, Rogosch, &
Maughan, 2000) are exceptions in this regard. Noteworthy, too, has been the clinical use of
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story stems to guide treatment and placement decisions for severely maltreated children
pioneered by Hodges, Steele, Hillman, and Henderson (2003).
In this special issue, five papers investigate how the child’s representations of relationships
are associated with pathological processes within specific diagnostic groups. Children
referred for Oppositional Defiance and Conduct Disorders are studied within attachment
theory by Green, Stanley, and Peters (2007) and Hill, Fonagy, Lancaster, and Broyden
(2007). As described below, Green et al. (2007) use a story stem method that is fully
informed by attachment theory and addresses questions about the role of maternal atypical
parenting and attachment disorganization in children presenting with severe behavioral
disruption. Hill et al. (2007), from within the theoretical framework of attachment pro-
cesses, address hypotheses about the contexts in which the capacity to interpret other’s
intentions is derailed in children’s constructed solutions to stories. The contribution to this
special issue by Schechter et al. (2007) also reflects attachment theory though a framework
of intergenerational transmission of insecurity and disorganization and studies children
whose mothers have repeatedly experienced domestic or family violence.
Two papers address questions about children referred for depression and mood
symptoms (Belden, Sullivan, & Luby, 2007; Beresford, Robinson, Holmberg, & Ross,
2007). These investigations also reflect attachment theory’s crucial role of the child’s inter-
nalization of safety and security within the family. In addition, Beresford et al. have drawn
upon the construct of affect regulation to examine how parent’s descriptions of the poorly
modulated, manic behavior of the child may be reflected in the child’s represented
experience within the family. The sixth paper in this collection, using a sample that includes
a sizeable number of clinic-referred children, remains at the level of broadband sym-
ptomology and addresses the important topic of social deficits and competence with peers
(von Klitzing, Stadelmann, & Perren, 2007). This particular topic has received very limited
attention in the story stem literature to date and the current paper provides an opportunity
to consider competencies that may co-occur with behavioral symptoms.
The move toward incorporating story stem methods into the diagnostic assessment
process has also gained momentum in recent years and has included a focus on the
particular concerns that arise in administering and interpreting story stems responses with
children presenting specific clusters of behavioral symptoms (e.g., attention deficits, or
symptoms of depression or mania). In this collection of papers, we make a strong bridge
toward understanding the representations and behavior regulation processes of children
whose families have sought professional assistance in supporting their care for them. The
goals for this special issue include consideration of some of these early efforts to investigate
the intrapsychic processes of children presenting with diverse problems and to encourage
incorporation of story stems into clinical practice to inform diagnosis from the child’s
perspective and to guide treatment planning.
The opportunities and challenges in working individually with clinic-referred children
have been discussed over the past decade through Robert Emde’s efforts at the Program for
Early Developmental Studies at the University of Colorado’s Department of Psychiatry.
These initiatives were spawned through collaborations at the Menninger Institute in the
 Story stems in clinical research and practice 181

1990s with Peter Fonagy and Jonathan Hill and expanded during the following decade to
broader efforts to engage a larger, worldwide group of child psychiatry clinical researchers
who had strong interests in exploring how story stems might play a role in diagnosis
and treatment formulation (e.g., at the University of Tampere Child Psychiatry Clinic,
Finland). Two widely attended meetings were convened that specifically sought to
understand the possibilities and necessary adaptations of the story stem method for clinical
practice and research. These meeting discussions serve as a very useful introduction to the
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theoretical and practical issues that arise when including story stem approaches in both
clinical practice and research endeavors. Several key points from those discussions are
summarized here.
The first of the ‘‘Clinical Narratives’’ meetings was held in 2004 at Chautauqua Park,
Boulder, CO, and focused exclusively on the MacArthur Story Stem Battery (MSSB;
Bretherton, Oppenheim, Emde, & the MacArthur Narrative Working Group, 2003)
approach. It included a group that was already familiar with the basic method and the body
of research about it. That 2-day retreat involved sharing of our research and clinical
agendas, especially bringing forward how an assessment tool that would meet the needs for
clinical practice might emerge from the highly standardized, research assessment. Those
needs included simplified training, live scoring, and methods for interpreting children’s
responses that are person-centered and allow for more profile-based approaches to
interpretation.
The second meeting occurred in 2006 at St. Catherine’s College, Oxford University, UK.
At that meeting, we embraced much greater diversity in story stem approaches; in addition
to the MSSB, we intensively studied the Manchester Child Attachment Story Task
(MCAST; Green et al., 2000); the Doll Play Interview (Murray, Woolgar, Briers, &
Hipwell, 1999); and the Story Stem Assessment Profile (SSAP; Hodges et al., 2003).
Common to all of the story stem approaches is that they seek to engage the child’s impulse to
respond to a challenging situation. Small differences exist in the degree of emotion included
in the ‘‘high point’’ of the stem before turning over to the child or in the amount of
‘‘displacement’’ of the child in the story from the child or in the use of props such as a doll
house and different types of figurines including animals. The approaches also vary in the
stimulus value of the stems. While MCAST consists of four attachment system stimulating
stems and SSAP includes 13 stems (eight MSSB stems as well as five other ‘‘animal stories’’
known as Little Piggy stories), the Doll Play Interview is not a fixed battery as it utilizes a
small number of story stems that are specific to the research or clinical question at hand. The
MSSB is in-between these two approaches; it is based on a core of 15 story stems, where
investigators and clinicians have created new stems to address specific issues. The current
collection of papers includes four investigations where new stems are studied and their
utility for elucidating specific behavioral symptom clusters is discussed (Belden et al., 2007;
Beresford et al., 2007; Hill et al., 2007; von Klitzing et al., 2007).
These differing approaches to story stems, however, also contain a strong commonality in
their ability to investigate processes involved in psychopathology, such as mania, defensive
avoidance, or loss of intentionality. Story stems challenge the child’s thought processes and
affect regulation as the child engages in construction and revision of a story’s resolution. The
diversity of story challenges in the MSSB approach enables us to consider the child’s
preoccupations as specific responses re-occur across administered stems. For example, we
may see themes of danger or abandonment that persist or intrude into story stem contexts
maladaptively, suggesting an over-generalized, script-like response to diverse social stimuli.
Thinking about a child’s response in this way also helps bridge to ideas in research on
depression about the role of rumination. In addition, diverse stems allow us to observe a
 182 J. L. Robinson

child’s ability to constructively problem solve in relation to specific types of challenges or,
alternatively, in the context of differing levels of displacement between the child and
characters across stories. Similarly, in the presence of low-arousing vs. high-arousing story
stem challenges, we may see differences in the content and processes of the child’s response.
This point, indeed, has been incorporated in two of the papers included in this special issue
(Beresford et al., 2007; Hill et al., 2007).
At the level of scoring, story stem approaches share important similarities and differences.
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Prosocial/empathic and antisocial representations are generally assessed in all of these

methods. Narrative coherence, disorganization, and avoidance are features of the child’s
story performance that are also of great interpretive interest across approaches. However,
specific definitions of content themes and of performance features differ based on the
theoretical orientation of the approach. Specifically, within the MCAST approach narrative
coherence, disorganization, and avoidance indicate specific features of the attachment
system and are used with other levels of analysis consistent with attachment theory by Green
et al. (2007). Scoring reflects the completion of the attachment cycle from proximity seeking
to caregiving and assuagement/soothing. However, within the MacArthur system of scoring
(Robinson & Mantz-Simmons, 2003), the meaning and definition of these terms is
associated with emotion regulation and cognitive processing abilities such as planning and
sequencing of the story. Narrative coherence reflects the child’s ability to address and
resolve the conflict while maintaining a storyline that makes sense; developmental increases
are expected in these behaviors across early and middle childhood. Although disorganization
is not explicitly coded within the MacArthur system, the derived construct reflects responses
that are incoherent and contain dysregulated aggression and negative affects, suggesting
cognitive processes that are interrupted by high emotionality. Green et al. (2007) consider
the executive/cognitive processes important potential ‘‘confounders’’ of the child’s attach-
ment narration, particularly when disorganization occurs episodically. A continuing debate
is whether the executive abilities that support story telling are ‘‘inside,’’ that is part of the
entire socioemotional and cognitive skills involved in constructing a narrative resolution, or
‘‘outside’’ of the child’s narrative and contribute to disruption of the narrative only in
particular narrative contexts. Results from two papers within this collection (Beresford et al.,
2007; Hill et al., 2007) seem to suggest the latter.
Avoidance is another interesting case to consider. Within the MCAST system, avoidant
behavior is used in the attachment theory sense of avoiding the expression of negative affect
and vulnerability in relation to the parent/caregiver. It implies a self-regulatory stance in
relation to distress rather than an interdependent regulatory stance. In their paper in this
special issue, Green and colleagues connect the child’s level of attachment disorganization
with mother’s expressed emotion, suggesting that the reflective functioning of the parent
may be seen echoed in the child’s emerging ability to reflect on relationships (Fonagy,
Gergely, Jurist, & Target, 2002). In a similar vein, Hill and colleagues identify avoidant
behavior in relation to distress/negative emotion; the child avoids distress and in some cases
may do so by lowering their intentional interpretation of others’ behaviors (Hill et al., 2007).
From yet another perspective, according to the MacArthur narrative scoring approach
(Robinson & Mantz-Simmons, 2003), avoidance refers to an inability to go forward in the
story or a defensive avoidance of the presented story conflict or the child’s own story
resolution. This defensive avoidance of the conflict, especially at the extreme observed in
dissociative behaviors (as identified by Macfie et al., 2001), proved to be an important
marker for the children of mothers with posttraumatic stress due to family violence
(Schechter et al., 2007) and for the mood disordered children in response to highly arousing
story stems in contrast to low-arousal stems (Beresford et al., 2007).
 Story stems in clinical research and practice 183

In the current collection of stories, we will also find many clinical practice concerns
echoed and discussed. While typically developing children are very responsive to engaging
with a friendly examiner in creating story stem narratives, children with substantial mood
disturbance have sometimes been overwhelmed by the content and/or mood induced in
particular story stems (Belden et al., 2007; Beresford et al., 2007; Schechter et al., 2007).
Empirical evidence of the potential for specific stems to stimulate the child’s ego-supportive
defensive processes as well as their inability to contain their emotional experience is
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important in our future efforts. Construing the central conflict of the story as the emotional
or relational challenge that we select to present to the child encourages the construction of
an individually tailored story stem battery or a battery tailored to a specific symptom cluster.
This deliberate approach to selecting story stems can be seen in all of the papers presented
here.
The papers in this special issue also suggest future directions to support our work with an
individual child. First, many research approaches to scoring have been variable-centered and
do not take into account the patterning of the child’s response across content and
performance dimensions; Green et al. (2007) is one exception. We need substantial
modification of scoring systems to simultaneously consider both the content and the
performance of the child’s narrative (Robinson & Kelsay, 2003). A profile-oriented
approach to scoring is highly desirable and is supported by ongoing story stem investigations
where large samples of low income children, representing high levels of ethnic/racial
diversity, have been evaluated on a range of story stems (Klute, 2004; Robinson, Oxford,
Spieker, & Klute, 2006). Second, clinicians are best served by understanding how the
patterns of response to story stems that are observed in specific groups of children vary
substantially from the typical. Undertaking a major norming study of these methods will be
highly valuable in this regard. As we collectively take the next steps in clinical research and
practice, a multi-symptom, multi-age study of this assessment approach will be invaluable.
These collected papers move forward aspects of theory and method that enable us to see the
possibilities of bringing the young child’s story more specifically into the diagnostic
treatment formulation process.

Acknowledgements
Invaluable assistance in reviewing manuscripts for this special issue was provided Robert
Emde, Sheridan Green, Kim Kelsay, Jenny Macfie, Timothy Page, and Susan Spieker.

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