Social Narrative Interventions for Students with Autism

SOCIAL NARRATIVE INTERVENTIONS FOR STUDENTS WITH AUTISM

A dissertation submitted to the Kent State University Graduate School of Education, Health and Human Services in partial fulfillment of the requirements for the degree of Doctor of Philosophy

by Suzanne Josephine Gikas August 2013

ii A dissertation written by

Suzanne Josephine Gikas

B.A. Honors, University of Essex, 1984

P.G.C.E., Canterbury, Christ Church College, 1993

M. Ed., Special Education, Kent State University, 2006

Approved by

______, Director, Doctoral Dissertation Committee Lyle Barton

______, Member, Doctoral Dissertation Committee Frank Sansosti

______, Member, Doctoral Dissertation Committee Sloane Burgess

Accepted by

______, Director, School of Lifespan Development and Mary Dellman-Jenkins Educational Sciences

______, Dean, College and Graduate School of Daniel F. Mahony Education, Health, and Human Services

iii

GIKAS, SUZANNE JOSEPHINE, Ph.D., AUGUST 2013 EDUCATION HEALTH AND HUMAN SERVICES

SOCIAL NARRATIVE INTERVENTIONS FOR STUDENTS WITH AUTISM (119 pp.)

Director of Dissertation: Lyle Barton, Ed.D.

In this study, a multiple baseline design across participants was used to evaluate the effects of a social narrative on teaching appropriate social skills to three students with autism. Currently, guidelines for Social Story™, as established by Carol Gray, have become very popular despite minimal scientific evidence to support their efficacy

(Bellini, Peters, Benner, & Hopf, 2007; Sansosti, Powell-Smith, & Kincaid, 2004;

Reynhout & Carter, 2006). This study deliberately deviates from Gray’s guidelines in an attempt to evaluate the contribution of the narrative to social literacy in students with autism.

ACKNOWLEDGMENTS

Without the advice, encouragement and support of my advisor, Dr. Lyle Barton, this dissertation would never have been completed. I would like to express my deepest gratitude to him for his wisdom, guidance, and good humor. I also thank Dr. Sansosti and Dr. Burgess wholeheartedly for their continual support, advice, expertise, and, above all, for the honor of agreeing to be part of my committee.

I thank my family, Jay, Faith, Lily, and Jake for their love and endurance, and for allowing me the time and space to pursue my goals, often at the expense of their own.

TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ...... iv

CHAPTER

I. INTRODUCTION AND REVIEW OF LITERATURE ...... 1 Definition ...... 1 Characteristics of Autism ...... 3 Social Interaction ...... 4 Peer Relationships ...... 6 Communication ...... 7 Theory of Mind ...... 8 Generalization ...... 10 Learning Styles ...... 12 Restricted and/or Repetitive Patterns of Behavior, Interests, and Activities ...... 12 Considerations for Designing Interventions ...... 13 Implications ...... 13 Research-Based Interventions ...... 14 Significance ...... 15 Social Story™ ...... 16 Definition ...... 16 Guidelines for Writing a Social Story™ ...... 17 Story Sentences ...... 19 Ratio ...... 21 Summary ...... 22 Review of Extant Social Story™ Research ...... 23 Background ...... 23 Research Analysis ...... 23 Analysis of Social Story™ Interventions for Students With Autism Research Synthesis Table ...... 26 Analysis of Guidelines ...... 27 Interpretation ...... 27 Guideline 1 ...... 27 Guideline 4 ...... 28 Guideline 7 ...... 29 Guideline 8 ...... 30 Guideline 9 ...... 30 Guideline Summary ...... 31 Confounds ...... 32 Research Design...... 34 v

AB Design ...... 35 Reversal/Withdrawal Designs ...... 35 Multiple Treatment Designs ...... 36 Multiple Baseline Designs ...... 37 Design Strengths ...... 40 Conclusion ...... 41 Purpose ...... 42

II. METHODOLOGY ...... 44 Participants ...... 44 Individual Participant Information ...... 44 Caleb ...... 44 David ...... 45 Charles ...... 46 Settings ...... 46 Procedures ...... 48 Recruitment ...... 48 Selection ...... 48 Permission ...... 49 Identification of Target Behaviors ...... 50 Caleb ...... 50 David ...... 50 Charles ...... 51 Dependent Measures ...... 51 Dependent measure for Caleb ...... 51 Dependent measure for David ...... 52 Dependent measure for Charles ...... 52 Dependent variables ...... 52 Design and Preparation of Interventions...... 54 Research Design ...... 54 Materials ...... 55 Social narrative ...... 55 Measures ...... 56 Inter-Observer Agreement ...... 57 Treatment Integrity ...... 59 Social Validity ...... 59 Pre-Baseline Preparation ...... 59 Baseline Phase ...... 60 Intervention Phase ...... 61 Follow up Phase for Maintenance ...... 62 Data Analysis ...... 62

III. RESULTS ...... 63 Outcomes of the Social Narrative Intervention ...... 63 Visual Inspection of Graphs ...... 65 Caleb ...... 65 David ...... 66 Charles ...... 67 The Nonoverlap of All Pairs ...... 68 Maintenance and Generalization...... 69 Maintenance ...... 69 Generalization ...... 70 Caleb ...... 70 David ...... 71 Charles ...... 71 Social Validity ...... 71 Procedural Integrity ...... 72 Conclusion ...... 73

IV. DISCUSSION ...... 75 The Social Narrative Intervention ...... 75 The Study ...... 75 Strengths of the Study ...... 76 Limitations ...... 78 Significance of Findings ...... 81 Implications...... 83 Social Change ...... 83

APPENDICES ...... 84 APPENDIX A. DIAGNOSTIC FEATURES OF AUTISM ...... 85 APPENDIX B. “ANALYSIS OF SOCIAL STORY™ INTERVENTIONS FOR STUDENTS WITH AUTISM” ...... 87 APPENDIX C. THE SOCIAL STORY™ VALIDITY CHECKLIST ...... 99 APPENDIX D. CONSENT FORMS ...... 102 APPENDIX E. CLASSROOM INTERVENTION QUESTIONNAIRE ...... 105

REFERENCES ...... 107

vii

CHAPTER I

INTRODUCTION AND REVIEW OF LITERATURE

In 1943, Austrian psychiatrist Dr. Leo Kanner used the term autism to describe a collection of unusual symptoms he had observed among the children he screened for emotional disturbance. At that time it was estimated that only 11, out of 20,000 children assessed, presented with the condition that was “markedly and uniquely different from anything reported so far” (Kanner, 1943, p. 217), what we now know as autism. Kanner noted the children’s ‘pathognomonic’ fundamental inability to “relate themselves to people and situations” and an “extreme autistic aloneness that, whenever possible, disregards, ignores, shuts out anything that comes to the child from outside” (Kanner,

1943, p. 26).

The last 60 years have witnessed a huge increase in the rate of children diagnosed with, what has subsequently been characterized as, a spectrum of related disorders;

Kanner’s observations form the basis of what is now more commonly referred to as

Autism Spectrum Disorder (ASD). Extant statistics portray 1 in 88 American children as having a diagnosis of autism, which translates to, on average, 1 in 54 boys and 1 in 270 girls (Center for Disease Control and Prevention, 2012). As such, autism is currently described as “the fastest growing developmental disability in the US” (Autism Support

Network, 2008).

Definition

Currently, the Diagnostic and Statistical Manual of Disorders-Fourth Edition

(DSM-IV-TR; APA, 2000) classifies autism within a range of disorders under the

1 2 umbrella category of Pervasive Developmental Disorders (PDD). Specifically, the PDD category includes Autistic Disorder, Asperger Disorder, and Pervasive Developmental

Disorder-Not Otherwise Specified. Although these disorders vary in number and severity of difficulties, the clinical and diagnostic characteristic of each of these disorders includes: (a) qualitative impairment in social interaction, (b) difficulties with lack of communication, and (c) restricted and/or repetitive patterns of behavior, interests and activities (APA, 2000). The social and communication difficulties of individuals with autism are dealt with more fully in this paper because they relate directly to the lack of social understanding that defines autism. The repetitive patterns of behavior are only briefly addressed in the context of intervention design. Since the line of inquiry is primarily focused on social skills interventions, Appendix A provides a detailed summary of the diagnostic features of the PDD category.

Since the late 1970s, categorization of individuals with autism and related conditions has been recognized as a spectrum of disorders, and referred to as ASD. The change of ASD from PDD has been used more frequently to account for the great variability in the severity and types of deficits observed (Gillberg & Coleman, 2000;

Quill, 1997), as well as the unique manifestations from one individual to another

(Sansosti & Powell-Smith, 2008). Traditionally, the term autism1, derived from the

Greek “auto” meaning “within oneself” which, by definition, contradicts the notion of

“socio” in social and society, was coined to mean “escape from reality.” However,

Kanner (1943) chose the term autism to epitomize the lack of interest in others displayed

1 The term autism is used in this paper to refer to Autism Spectrum Disorder.

3 by those children that he had observed. Although the social skills difficulties experienced by individuals with autism bear testament to the solitary nature of this condition, contemporary understanding of the breadth of impairment calls for consideration of autism as a spectrum of disorders.

Characteristics of Autism

Autism is a complex neurological disability that impacts multiple areas of development throughout the lifespan (Brownell, 2002) and is characterized by impairments in socialization, communication, and restricted and/or repetitive patterns of behavior (DSM-IV-TR; APA, 2000). Autism is a spectrum disorder which presents very differently in different individuals and can range from being very mild and barely detectable to presenting major impairments in many areas. While this section focuses on social impairments that present, it should be noted that social communication skills span a wide range and that some individuals exhibit unexceptional social skills. Typically, autism is detectable in children before the age of 3 and often as early as 15-18 months, and it does not appear to be confined to a particular socio-economic strata, race, or population. To date, extant literature has not yet identified a specific cause and there is no known permanent cure. However, research conducted internationally through the

Autism Genome Project has recently reported findings that “autism is caused in part by rare genetic changes” (Sahm, 2010).

While a “triad of impairments characterizes autism,” markedly abnormal or impaired development in understanding and functioning socially is the hallmark feature that affects all aspects of interaction, communication, and behavior. For purposes of this

4 review, the following section provides an in-depth synthesis of the defining features of social interaction and communication as set forth in the DSM-IV-TR (APA, 2000) to expand on some of the distinct characteristics and manifestations of both. Such a synthesis is supported using Baron Cohen’s concept of “Theory of Mind” (ToM), which has been included to offer an important explanation of how lack of social skills may be related to a fundamental deficit in perspective taking skills. An explanation of generalization follows, which is a defining learning characteristic that must be taken into consideration for designing interventions in the section that follows. Finally, there is a brief explanation of how rote behaviors, that is, restricted and/or repetitive patterns of behavior, interests, and activities (APA, 2000), impact teaching and learning styles and can be used to inform interventions.

Social Interaction

Social interaction encompasses a wide repertoire of skills necessary for acknowledging basic signals such as eye contact, facial expressions, and physical gestures, as well as understanding more sophisticated cultural nuances such as body language, proximity, signals, and other social cues. Failure to understand both basic and nuanced cues from the social world often results in difficulty initiating, responding to, and/or maintaining interactions with others. As a result, most social situations are problematic for even the most capable individuals with autism (Kuoch & Mirenda, 2003;

Kuttler & Myles, 1998).

Difficulties in social interactions emerge at an early age for individuals with autism. Although typically-developing children learn to observe their parents’ signals of

5 danger, approval, impatience, and so forth, children with autism typically are unable to decode their parents’ communicative gaze, gestures, and body language (i.e., paralinguistic signals). As such, children with autism fail to make eye contact or socially modulate their gaze to initiate, terminate, or regulate their social interactions, even at this very basic level. Often their gaze is limited in flexibility, appropriateness, or context. In addition, a person with autism may not exhibit any facial expression or be able to process social information through reading expressions or cues of others. Vocalization may be unaccompanied by subtle changes in gaze, facial expression, or gesture. Children with autism need to learn to interpret non-verbal language.

Social rules and conventions that typical individuals appear to understand without difficulty can be problematic for students with autism and often have to be taught directly, for example: turn taking, waiting in line, shaking hands, and expressions of approval. Similarly, some students may have difficulty understanding that it is not appropriate to hug strangers when it is acceptable to hug parents. Secondary perception skills are also deficient, for example the ability to translate simple social information, such as a coat on a vacant chair, or a glass on a table, that usually indicates that someone is sitting there, but is temporarily absent (Gombrich, 1961).

In addition to difficulties with basic social interactions, individuals with autism often lack the desire to have accomplishments reaffirmed through praise; bring objects to show to others; or demonstrate joint attention skills (Lord, Rutter, DiLavore, & Risi,

2009). That is, individuals with autism often demonstrate no pleasure or interest in social interactions, or in others’ conversation. Instead, individuals with autism likely will

6 perseverate on a topic of interest, unaware of whether the listener is interested (Myles &

Simpson, 1997). For example, a student may continue to talk about a computer game regardless of the nonverbal behaviors of the listener that suggest boredom; interpret listener comments in the context of a computer game; or fail to respond to the initiations of others, as if they are unaware of their presence. Despite such poor reciprocation, an individual with autism likely will show pleasure in his or her own actions or his or her own part in conversation. Given such difficulties in sharing of social information, many individuals with autism are further ostracized from their social contexts.

Peer Relationships

As a result of misinterpretation of social information, combined with a failure to share in social relationships with others, students with autism tend not to engage socially.

Early on, such difficulties likely affect play. The (DSM-IV-TR; APA, 2000) states that individuals with autism may appear intensely preoccupied, prefer solitary activities, and demonstrate difficulty relating to others. In a preschool setting it is not uncommon to see a group of children playing together at their developmental level while the child with autism is alone and seemingly preoccupied by a solitary activity (e.g., spinning or self- stimulatory behavior). A toddler with autism may not turn around when called and appear to be unaware of peers and surroundings and uninterested in playing or any kind of interaction (Church, Alisanski, & Amunullah, 2000). Siegel (2003, p. 116) questioned the “salience of peers” for students with autism, for whom group membership does not appear to be intrinsically important. Similarly, the feelings, perspectives, and points of view of others appear to be unimportant to students with autism.

Communication

Impairments in communication include deficits in spoken language as well as in non-verbal areas of communication. Many students with autism demonstrate extreme difficulty using and understanding spoken language. In fact, some children with autism may never learn the speech and language skills needed to communicate functionally in daily living (Griffith & Ripich, 1999). For others, delayed or deviant communication development can range anywhere from total lack of speech; speech that is present at around 12-18 months and is then lost completely; or speech that may develop later in childhood (Center for Disease Control, 2010). Impaired speech may be characterized by unusual intonation, volume, rhythm, and rate; immediate echolalia; and stereotyped use of words. “Even when language develops, semantic and pragmatic dimensions are usually much more affected than phonetics, vocabulary, or syntax” (Plumet & Tardif,

2005, p. 2). Moreover, students who are able to speak adequately often use speech only to communicate a need, not to initiate or sustain conversation.

Reciprocal conversation skills also are very difficult. Often students with autism do not initiate conversations, offer spontaneous (relevant) information, or seek information from others (citations). Spoken language often appears to fulfill a functional rather than a social purpose for individuals with autism. For example, if asked, “How are you?” a student with autism may respond by giving his or her age since there appears to be limited understanding of communication as a strictly social vehicle. Additionally speech may be used routinely for no apparent social purpose (e.g., an individual will

8 repeat segments of a movie or television show or phrases that may or may not be directed at a peer) and incorporate idiosyncratic language to no communicative end.

Atypical communication and social development can perpetuate a cycle of behavior problems for children with autism. Very often, this undesirable behavior serves as a form of communication when language and social development are absent or delayed

(Delano & Snell, 2006). In addition, misreading social cues may result in unusual responses, which, in turn, are met with disapproval from peers and educators so that the student with autism may be less likely to attempt social interactions in the future

(Brownell, 2002). For example, something as seemingly inoffensive as a play invitation, which involves getting into a student’s physical space, may result in a tantrum simply because the student with autism may consider the invitation to be an invasion of personal space but not have the skills or understanding to communicate his or her discomfort in a more socially acceptable manner. Unfortunately, educators often misconstrue disruptive and inappropriate behaviors of children with autism as a lack of impulse control rather than an absence of necessary skills (Sansosti & Powell-Smith, 2006) or the lack of perspective taking skills described in Baron-Cohen’s ToM (Baron-Cohen, Leslie, &

Frith, 1985). Furthermore, as a result of their lack of social skills, students with autism are often subject to ridicule and alienation (Sansosti & Powell-Smith, 2006).

Theory of Mind

Theory of Mind has its roots in psychology’s social cognition theory, and “studies the individual within a social or cultural context and focuses on how people perceive and interpret information they generate themselves” (Huitt, 2006). The theoretical

9 assumption is that individuals react and respond to objects and beings in their environment and learn to adjust their behavior and responses accordingly through this interaction. Since children with autism demonstrate little awareness of others or objects, then understanding thoughts, feelings, mental states, and beliefs of others is often limited.

Theory of Mind (ToM; Baron-Cohen et al., 1985) asserts that students with autism cannot easily perceive the thoughts and state of mind of others. This is often referred to as

‘mindblindness’ (Siegel, 2003, p. 65), “the ability to know what other people know, want, believe, and feel, and how this influences their behavior.” Theory of Mind has been used to explain why the core deficits in socialization might occur; as the result of the inability to comprehend that others have a point of view or that a point of view can differ from their own. This is well demonstrated in a “classic” ToM task, the Sally Anne false belief task. In the task, two children, Sally and Anne, have a marble. Children witness Sally putting the marble in her basket. When Sally has left, Anne removes the marble and puts it in her own basket. Usually, typically developing children by the age of 3 or 4 years will understand that Sally will return and look for the marble where she left it, since that is her understanding or point of view regarding the location of the marble. Many children with autism will state that Sally will look in Anne’s basket, not recognizing that Sally has different knowledge than they do (i.e., they have seen Anne move the marble, but Sally has not). So, assuming that children have the language proficiency to understand the meaning of the question, where “will Sally look,” or “should Sally look,” one can deduce that the student with autism cannot easily take another person’s perspective or understand another person’s “mind” (Baron-Cohen et al., 1985).

ToM explains that children with autism experience difficulty in their social interactions because they are unaware of others’ points of view. Therefore, without ToM, or the ability to infer the mental states of others, individuals with autism are unable to predict the behavior of others. If children with autism cannot relate to others’ feelings then, according to social cognition theory, they cannot accommodate for others’ feelings in their responding. T of M explains how tasks that are self-serving are easier for individuals with autism to comprehend. Ultimately, such lack of social cognition or T of

M underlies behavior problems that often ensue as a consequence.

Generalization

Social-Communicative and other skills have to be learned. In addition, such skills have to be applied across situations. This concept is referred to as generalization.

Generalization is problematic for students with autism because learning skills in one environment does not presuppose that these skills can be performed elsewhere. A key difference between typical students’ learning and learning of students with autism is that, early on, typical children learn to generalize (e.g., many dog species are unalike yet an inherent concept of dog is realized and applied to a variety of dog species). Similarly, a young child will soon learn how to generalize different looking toys (e.g., a stuffed cow and a plastic cow; Siegel, 2003). Grandin (2006), an accomplished adult with autism, described herself as a visual thinker and stated that she, like many others with autism, accesses information through visual not language-based memory. Grandin asserted that her visual memory impacts generalization wherein, for example, her own animal concept would consist of a series of animal videos as opposed to a more generic visual concept

11 held by ‘normal’ people (Grandin, 2006). In Grandin’s case the visual repertoire helps her navigate and understand her environment.

Generalization skills do not appear to be imbued in students with autism in the same way and must be directly taught (Reynhout & Carter, 2006). Moreover, generalization of more abstract social skills and customs (e.g., greetings) need to be accommodated within teaching strategies. An ability to generalize may also help overcome the characteristic desire for sameness and rigid adherence to routines and rituals, as well as the inability to transition. When individuals are able to generalize they are able to make connections and relate information to familiar situations. Generalization skills are skills wherein an individual can relate information meaningfully so that an event or activity is purposeful. Generalization presents significant challenges to the educator since it is impossible to teach every response to every presenting situation.

Siegel (2003) asserted that where there is no social reference or intrinsic motivation, generalization will not occur, and that generalization is not taught solely by shaping or putting actions into a narrative. If the child does not recognize the components of the narrative then future variations on the theme will not be promoted. Furthermore, students may appear to demonstrate generalization skills without understanding the social value of the act and social development may still be inhibited. For example, a student may be taught to differentiate between “How are you?” and “How old are you?” and respond appropriately in many different greeting scenarios without understanding why it is customary to greet anyone.

Learning Styles

As Grandin (2006) noted, individuals with autism often tend to be visual learners and have difficulty with sequencing, for example, Grandin explained how she internalized a series of individual images that help her understand and retrieve information Images are effective for conveying, organizing and sequencing information and routines for individuals with autism and are often used to help promote the predictable environment that appeals to the rote/repetitive aspect of autism.

Restricted and/or Repetitive Patterns of Behavior, Interests, and Activities

The third area of diagnostic criteria describes restricted and/or repetitive patterns of behavior, interests, and activities (APA, 2000). The salient characteristic, in the context of designing interventions for individuals with autism, is portrayed by inflexible adherence to specific routines. This can be a ‘two-edged sword,’ when adherence to routine is crucial, “repetitiveness can also work to the individual’s benefit by using the drive for routine as a prosocial strategy to organize activity in a functional, albeit highly structured and repetitive manner” (Siegel, 2003, p. 235).

As illustrated above, the deficits characterized by autism permeate every aspect of social interaction, communication, and behavior from general social rules to very specific aspects of interpersonal communication and understanding. The literature addresses several crucial areas such as: inability to interpret and derive meaningful information from social cues; difficulty with social conventions; communication; perspective taking; a propensity towards visual learning; difficulty relating to others; ridicule; alienation; absence of peer relationships; and inflexibility with routines. Moreover, praise and

13 sharing with other students may not be motivators for students with autism. Interventions should focus on the learning styles that characterize autism. Therefore interventions should consider generalization, behavior, visual learning strengths, and supportive routines in the context of the social deficits to be overcome. Furthermore, interventions should be sufficiently discreet so that they do not perpetuate stigma and alienation.

These areas are explored more fully in the following section.

Considerations for Designing Interventions

Implications

Since social skills deficits are the hallmark characteristic of autism, then improving social functioning is a critical target for intervention. It is important that intervention strategies are based on the contemporary understanding of the challenges exhibited by children with autism (Simpson et al., 2005). Specifically, highly individualized interventions are needed that teach culturally appropriate social skills in a manner that is discreet and unobtrusive (i.e., less stigmatizing) for use in a variety of settings (Sansosti & Powell-Smith, 2008). The need for discreet interventions may be especially important within inclusive contexts so that it does not negatively impact the social status of some students with disabilities (Palley, 2006). Lee and Odom (1996) noted that disability has an effect on social inclusion and can isolate the student from engaging in social and learning opportunities. Therefore, interventions must be discreet enough to avoid social stigmatization. In addition, programming for social skill interventions should include training for maintenance and generalization. Reynhout and

Carter (2006) stated that programming for maintenance and generalization are essential

14 components of an effective intervention but they are often inadequately addressed in intervention research? When programming for maintenance and generalization are not addressed, then teachers face the impossible task of trying to re-teach skills in every setting. Interventions must be individualized to target social deficiencies as early as possible. Programming for communication and social interaction must be continually addressed, with the wider aim of transition into society as the key objective.

Strategies also should incorporate the visual learning strengths of students with autism. Grandin (2006) described children with autism as “visual thinkers” and emphasized that written instructions help children with autism perform best compared to verbal instructions because visual information is easier for them to understand. In addition, intervention strategies should incorporate the preference of children with autism to follow routines. Children with autism also prefer rigid, predictable routines and therefore this characteristic ‘strength’ should be maximized in their programming.

Interventionists also must observe the legal mandates in the No Child Left Behind Act

(NCLB, 2001) and the Individuals with Disabilities Education Improvement Act (IDEIA,

2004) that call for interventions that are evidence-based.

Research-Based Interventions

The Individuals with Disabilities Education Improvement Act (IDEIA, 2004) and

The No Child Left Behind Act (NCLB, 2001) emphasize increased accountability in educational practice. Specifically, these laws warrant utilization of research-based and scientifically based interventions. NCLB (2001) promotes accountability regardless of a student’s disability and establishes rigorous and extensive data collection and reporting

15 standards. IDEIA (2004) mandates that educational establishments in receipt of federal funding must be able to identify and implement socially validated, research-based interventions that are scientifically proven to be efficacious for all students with disabilities.

Significance

In 2006, Professor Michael Ganz, of Harvard Public School of Health, estimated the lifetime cost of caring for an individual with autism to be approximately $3.2 million with the overall cost to society at approximately $35 billion. In summary, the prevalence rate, severity of needs, and cost of service warrant exploration of meaningful interventions that address core areas of deficit for individuals with autism. Based on the overview of deficits and characteristics of autism outlined above, interventions must satisfy several criteria: (a) they must be supported by empirical evidence; (b) they must be conceptualized and implemented to promote generalization; and (c) they must have the potential to address the triad of impairments described in the DSM-IV-TR (APA, 2000).

In addition, they need to be sufficiently discreet, appropriate, and non-stigmatizing so that they promote social acceptance among peers. There is a growing body of research that indicates that a Social Story™ (SS™) is an optimal intervention that can accommodate the needs of individuals with autism and fulfills many of the above criteria.

A Social Story™ can be used to promote generalization as it can be implemented across environments and tailored to any purpose or situation; it is discreet and can be read privately by the student for whom the intervention is designed (or peer or adult) and it is not time consuming. A SS™ has the scope to address any situation so has a wide variety

16 of applications. A SS™ is visual, with or without illustrations, and students with autism tend to benefit from visuals. A Social Story™ is intended to be read and reiterated and can also be easily inserted into routines and so appeals to the rote learning style attributed to students with autism.

Social Story™

Definition

A SS™, introduced by Carol Gray in 1991, is a brief, individualized story specifically designed to target social skills and other deficits through identifying and sharing information that supports more effective responses. A SS™ describes a particular social situation and provides specific response cues through visual supports and text. Social Story™ appears to be a promising and positive intervention to address the social, behavioral, and academic learning difficulties of students with autism (Kokina &

Kern, 2010; Reynhout & Carter, 2006; Sansosti, Powell-Smith, & Kincaid, 2004) and are included as evidence based interventions (see Frank Porter Graham EBP briefs, and NAC

NSP). Moreover, SS™ can be focused on key areas such as social interaction to specifically benefit the needs of students with autism (Reynhout & Carter, 2006). SS™ puts the student in direct contact with relevant information without the complexity of personal interaction (Scattone, Edwards, Wilczynski, & Rabian, 2002), and thereby minimizes the confusion of verbal instructions and social interaction (Gray & Garand,

1993). Attwood (1998) further described SS™ as vehicles to provide information on what people in a given situation are doing, thinking, or feeling, the sequence of events, the identification of significant social cues and their meaning, and the scripts of what to

17 do or say; in other words, the what, when, who, and why aspects. From this perspective,

SS™ appears to have direct connection to Baron-Cohen’s “Theory of Mind” (Baron-

Cohen et al., 1985), as they can be used to explain others’ perspectives (Atwood, 1998) and “teach the student to understand consequences of their own and others’ actions so they are able to read, interpret, and respond effectively to their social world” (Gray, 1994, p. 5). Creation of a SS™ may be described as an artful science because it requires an interventionist to understand both the social skills deficits of the child and the environmental characteristics that occasion or maintain the child’s inappropriate or ineffective behavior, as well as careful adherence to the guidelines outlined by Gray

(2004).

Guidelines for Writing a Social Story™

The purpose of the story should be to provide understanding of social rules and norms and to guide, as opposed to direct, desired behavior. The SS™ should be generated to address a specific area of difficulty and help overcome problems or deficits by providing information that will help a student understand and know how to respond to situations. Gray’s (2004) guidelines follow:

1. A SS™ meaningfully shares social information with an overall patient and

reassuring quality. (If this is a story teaching a new concept or skill another is

developed to praise a child’s positive qualities, behaviors, or achievements.)

2. The story has an introduction that clearly identifies the topic, a body that adds

detail, and a conclusion that reinforces and summarizes the information.

3. The story provides answers to the “wh” questions, describing the setting or

context (WHERE), time related information (WHEN), relevant people

(WHO), important clues (WHAT), basic activities, behaviors, or statements

(HOW), and the reasons or rationale behind them (WHY).

4. The story is written from a first person perspective, as though the child is

describing the event (most often for a younger or severely challenged child),

or third person perspective, like a newspaper article (usually for a more

advanced child or an adolescent or adult).

5. The story uses positive language, omitting descriptions or references to

challenging behaviors in favor of identifying positive responses.

6. The story is comprised of descriptive sentences (objective, often observable

statements of fact), with an option of any one or more of the following

sentence types: perspective sentences (that describe the thoughts, feelings

and/or beliefs of other people); cooperative sentences (to explain what others

will do in support of the child); directive sentences (that identify suggested

responses or choices of responses to a given situation); affirmative sentences

(that enhance the meaning of surrounding statements); and/or control

sentences (developed by the child to help him/her recall and apply information

in the story).

7. The story follows the SS™ formula: DESCRIBE (descriptive + perspective +

Cooperative + affirmative sentences ≥ 2 *DIRECT (directive + control

sentences). (*If there are no directive and/or control sentences, use 1 instead

of 0 as the denominator.)

8. The story matches the ability and interests of the audience, and is literally

accurate (exception: if analogies and/or metaphors are used).

9. If appropriate, the story uses carefully selected illustrations that are

meaningful for the child and enhance the meaning of the text.

10. The title of the story meets all SS™ criteria. (p. 21)

Story Sentences. SS™ are uniquely tailored to benefit students with autism: they are unambiguous; they are clear, concise, and explicit; and they can be individualized to reflect the student’s and others’ perspectives. That is, the content of the SS™ provides information to help an individual facilitate greater social understanding and, subsequently, more appropriately navigate social situations. Whereas narratives (e.g., parables, fairy tales, fables, and other genres of story) have been widely used throughout history for the purposes of teaching and imparting information, a SS™ is differentiated and characterized by a specific formula and particular sentence types (see items 6 and 7 above). Gray maintained that the success of SS™ is attributable to these key elements and emphasized that any story that does not conform to these guidelines is simply not a

SS™ (Gray, 2004); therefore Gray asserted that the unique formula and sentence types define SS™. The following is an example of a SS™ that has been constructed in accordance with Gray’s recommendations with a further explanation of sentence types (in parenthesis) and ratio.

Playing

At school many children play games on the playground at recess. (Descriptive)

Usually, playing is a lot of fun. (Perspective)

I will try to ask someone to play. (Directive)

Playing is a fun thing to do. (Affirmative)

If I ask to play with someone they may play with me. (Cooperative)

Playing with others is fun for them. (Perspective)

The first sentence in the SS™ above is descriptive. Descriptive sentences are fact, not opinion; they are logical, accurate, and likely to be reassuring. Gray (2004) described these sentences as the backbone of the story and the only required type of sentence. Descriptive sentences contextualize the SS™ and offer relevant information.

The second and final sentences, above, are perspective sentences; these describe a person’s internal state. Perspective sentences are only used to describe the student’s perspective if it expresses a positive feeling, otherwise they are used to describe the internal feelings of other people (e.g., “knowledge, thoughts, feelings, beliefs, opinions, motivation or condition/health” [Gray, 2004, p. 7]). The example above provides a positive statement of how the subject feels about playing, in the second sentence, and concludes with a final sentence that offers another’s perspective. Perspective sentences accord with ToM by reminding the student that others have opinions and feelings. The third, directive sentence, identifies a “response or choice of responses to a situation or concept” (p. 7). The directive sentence “suggests” a response and is often couched in terms like “I may” or (above) I “will try to” so that there is room for potential error and

21 diminishes the imperative tone of the directive. The next sentence, affirmative, usually follows the descriptive. The role is simply to “stress an important point, refer to a law or rule, or reassure” (p. 8). Cooperative sentences identify what others may do to assist

(e.g., they may play with me). Gray also included the option of a control sentence; these

“are statements that are written by a child with autism to identify personal strategies to recall and apply information” (p. 8). For example, “if there’s a tornado my mom or dad can help me hide near the water heater” (p. 8). In the above SS™ example only the final perspective sentence, the affirmative sentence, and the descriptive sentence make a definite statement; the other sentences are non-committal so that while the SS™ should be as accurate as possible, the student cannot be set up for failure. For example, a SS™ that stated “when I ask someone they will play with me”, does not accommodate for potential refusal that could occur.

Ratio. The other defining characteristic of the SS™ is Gray’s ratio (guideline 7 above). The ratio is a formula that defines the relationship between the different sentences in the SS™. The rationale is that the SS™ guides rather than directs and so the

SS™ must be constructed to this effect. The ratio should be calculated by putting the total number of sentences that describe in the numerator and those that direct or control as the denominator. A correctly constructed SS™ always yields an answer of 2 or more.

If the answer is less than 2 then the story is not a SS™.

Guidelines for designing and implementing SS™ are discussed at length in the

Review of Literature section to reflect different author interpretations, and several amendments and updates by Gray. Four features of the guidelines for implementation

22 remain constant throughout the amendments. First, the SS™ is produced in visual format; second, the SS™ is read aloud; third, the SS™ is read 1:1; fourth, the same SS™ is reiterated for several days with no change to the script (even in studies where there is more than one SS™ per student). These parameters always guide the implementation process although the SS™ may be implemented in different ways, for example, in written format, musically, using a computer, or other technical device.

Summary

SS™ is an intervention that is purposefully conceptualized to address the significant social challenges that characterize autism. Currently there are 33 published research studies (excluding meta-analyses), where SS™ is the independent variable, that report increases in various aspects of social functioning (and one that does not). Despite the National Autism Center’s (NAC) recent acknowledgement of SS™ as an evidence-based practice and wide acclaim and social validation, there is no study that irrefutably links the outcome to the specific requirements of the SS™ formula as opposed to a general narrative strategy. The following discussion focuses on identifying evidence that efficacy can be attributed solely to SS™ where SS™ meets the definitive criteria stipulated by Gray (i.e., where SS™ follows the unique ratio, guidelines, and all qualifying features of SS™) emphasized above. Since SS™ is conceived of rules then evidence should substantiate the relevance of the rules to the intervention and thus set

SS™ apart from other narrative types.

Review of Extant Social Story™ Research

Background

The purpose of the following review of literature is to evaluate the scientific basis and potential use of SS™ within school programs as an intervention for students with autism. EBSCO and PsychINFO databases were used to search for the terms “Social

Story” research studies published in “peer reviewed journals.” The search included students eligible for services under IDEA (1997), aged between 3-21 years; studies where the independent variable was SS™; and studies using a single subject research design, dating from 1995, when the first research on SS™ was conducted (Swaggart & Gagnon,

1995), until October 2008. Thirty-four studies were located and, of these, 33 reported positive findings. However, these findings are contradicted by three meta-analyses conducted by Bellini, Peters, Benner, and Hopf (2007); Sansosti et al. (2004); and

Reynhout and Carter (2006), who concluded that there is limited evidence to support the efficacy of SS™. The contradiction has arisen largely due to a lack of consistency and rigor in data collection methods and agreement as to what demonstrates efficacy. A fourth, more recent, meta-analysis published by Kokina and Kern (2010) reiterated previous findings regarding “questionable effectiveness of Social Story interventions for students with ASD” (p. 822). The meta-analyses are briefly discussed in the following section.

Research Analysis

A meta-analysis conducted by Sansosti et al. (2004) reported that SS™ showed limited evidence of being effective in reducing target behaviors and no evidence was

24 found to support acquisition of new skills. Reynhout and Carter (2006) concluded that, despite favorable research findings in support of SS™, when the percentage of non- overlapping data (PND) were interpreted, overall values suggested that SS™ were, at best, marginally effective.

Bellini et al. (2007) conducted a meta-analysis of 55 social skills interventions, including SS™ using a quantitative metric to evaluate treatment effectiveness. The interventions analyzed by Bellini et al (2007) included environmental, child specific, collateral, peer mediated and comprehensive. Criteria employed were: did the strategy match the intervention strategy to the type of skill deficit? What were the intervention, maintenance, and generalization effects as measured by the percentage of non- overlapping data points? The results of Bellini et al.’s meta-analysis “suggests that school-based social skills interventions were minimally effective for children with autism” (p. 1) although researchers were unable to compare the outcomes of SS™ against other social skills strategies. However, Bellini et al. recommended that future research elucidate the procedural features that lead to the most beneficial social outcomes for students with autism.

Kokina and Kern (2010) described some considerations potentially associated with higher effectiveness of a SS™, particularly for students with higher comprehension levels, such as method of delivery, timing and duration of implementation, setting, participant characteristics and selection, type and complexity of intervention (i.e., targeting reductions in appropriate behavior), baseline assessments, age and skill levels, and levels of challenging behavior and recommended that future research should attempt

25 to clarify which of these variables determines outcomes and attempt to parcel out the effects of SS™ from other effects.

Contradictions between findings from the meta-analyses and individual studies may be explained by the fact that “examinations of the effectiveness of SS™ have been primarily informal and based predominantly on the observations and reports of parents and teachers” (Norris & Dattilo, 1999, p. 182) who were knowledgeable about the SS™ intervention as opposed to having been based on clinical data; therefore a more detailed exploration of the 34 studies is warranted to seek more scientific endorsement.

This review of literature extends previous research and examines all studies to date in search of scientific evidence to support the efficacy of Carol Gray’s SS™. Gray emphasized that SS™ is defined by strict guidelines and ratio, and these two factors, in essence, epitomize SS™. To this end, only studies that adhere to Gray’s guidelines were considered or evaluated. Stories that do not conform to Gray’s recommendations were not used to endorse the validity of SS™ since, as Gray asserted, they are not SS™. In fact, the most recent version of Gray’s guidelines (above) was produced with the specific aim of clearly delineating what is, and is not, a SS™. Gray emphasized that “the original

Social Story™ Guidelines have been expanded and reorganized into 10 defining characteristics; criteria and guidelines that clearly distinguish Social Story™ from fiction and traditional non-fiction, task analyses, social scripts or other visual strategies” (Gray,

2004, p. 2). Therefore, the point to be clearly underscored is that SS™ is not an arbitrary, generic narrative but a carefully conceived, explicitly stated intervention.

Analysis of Social Story™ Interventions for Students With Autism Research

Synthesis Table

A comprehensive overview of literature is challenging for many reasons. The guidelines that were introduced in 1991 have been subject to several revisions. Although

Gray (2004) asserted that the guidelines have changed very little since their inception, the studies examined vary in which guidelines they observe. Similarly, some authors follow guidelines for the creation of the SS™ but not for implementation. As such, comparison and analysis of studies becomes a somewhat difficult task. Many studies use SS™ in conjunction with other interventions and thus introduce multiple treatment interference.

There also are a plethora of methodological flaws contained within the type of research designs employed that lead to questionable levels of experimental control. Ultimately, although anecdotal support is persuasive, it does not constitute the empirical support sought in IDEIA (2004) and NCLB (2001). To facilitate comparison and analysis of extant studies specific details from the studies reviewed have been entered in a table,

“Analysis of Social Story™ Interventions for Students with Autism” (see Appendix B), which provides a comprehensive and detailed overview of 34 studies.

The “Analysis of Social Story™ interventions for students with Autism” (see

Appendix B) was constructed as a map for comparing studies. Studies are organized in rows by disability category and arranged in chronological order within each category, to show the progression of research in tandem with the revisions to guidelines generated by

Gray (2004). For example, the first 16 studies listed on the table were conducted using participants with a diagnosis of autism; the next 7 studies featured participants with a

27 diagnosis of Asperger syndrome, and these are followed by studies that described students as having autism spectrum disorder, high functioning autism, and other disability areas such as PDD-NOS or co-morbid conditions. Many headings are self-explanatory and require no explanation. Column 17 indicates whether guidelines were fully, partly, or not followed. In this column (e.g., where guidelines have been followed) the letter F indicates that they were followed and the date of the guidelines cited. Sections of primary concern are sections that may demonstrate a causal link between the intervention

SS™ and the outcome (i.e., adherence to guidelines, independent variables and confounds, and research design). These are explored more fully in the following sections: Analysis of Guidelines, Confounds, and Research Design.

Analysis of Guidelines

Interpretation

This section reviews guidelines over an 11-year span and notes how change has impacted the studies. Gray’s most recent publication (2004) reiterated and clarified guidelines while noting some common misconceptions. The extent to which guidelines are followed makes the case for whether there is any substance to SS™ since notably 33 of 34 studies report positive findings that they attribute to SS™. Significant problems with interpretation of guidelines 1, 4, 7, 8, and 9 are discussed below respectively.

Guideline 1. None of the studies reveal how guideline 1 was followed, specifically, that a story should be developed to praise the child’s positive qualities if a new skill or concept is being taught (Gray, 2004). Gray recommended that SS™ is constructed to affirm what a child currently does well 50% of the time. Authors do not

28 specify whether the students were introduced to the intervention as recommended.

Additionally, there are no reports of positive/affirming data being gathered in support of this guideline. Reynhout and Carter (2006) reported that 90% of the stories they evaluated used positive “consequences lines” in accordance with Gray’s guideline 1.

However, this is not strictly in keeping with the intent of the guideline, since guideline 1 emphasizes that the story should affirm what is already done well rather than offering positive consequences for future actions.

Gray’s explanation of guideline 1 also emphasizes that the most commonly misconceived goal (Gray, 2004, p. 3) is changing behavior. There are 12 examples of interventions (Appendix B, column 7) that aim to change behavior (e.g., reduce, decrease, or target a negative behavior). Notably, all studies that used SS™ to target aberrant behavior reported that the intervention was effective with the exception of two students (out of five) in the study conducted by Toplis and Hadwin (2006).

The intent, according to Gray (2004), should be “to focus on the underlying causes of frustration” and “to identify and share information that supports more effective responses” not “to make our lives as parents and professionals a little easier”

(p. 3). Only four studies used a Motivation Assessment Scale to assess what may motivate students or provoke frustration (Durand & Crimmins, 1992) and only three that used a functional analysis to attempt to determine the underlying frustration as recommended by Gray. (Appendix B, column 4).

Guideline 4. Changes in guideline 4 may have generated confusion. Initially first person language was not recommended in Gray’s 2000a and 2000b and Gray and

White’s 2003 guidelines. Reynhout and Carter (2006) found that 47% of SS™ were written in first person, from the perspective of the participant (i.e., authors had disregarded the 2000a, 2000b, and 2003 guidelines which were current to their research).

Gray’s 2004 guidelines were revised to assert that first-person perspective is “often the best choice when writing for younger or more severely challenged children” (p. 5) suggesting that Gray is responsive to research findings.

Guideline 7. Gray and Garand’s (1993) original guidelines featured three sentence types: (a) descriptive, (b) directive, and (c) perspective sentences. There was no specified ratio. The ratio of sentence types was introduced in 1995 to avoid a list of directives being presented to a student. Hutchins and Prelock (2006, p. 49) argued that

“Gray’s ratio reflects her preference to avoid merely listing behaviors that the individual is expected to perform and the rationale is not rooted in theory or empiricism.” Gray’s rationale, however, is that giving lists of directives is inevitably a strategy that has already been tried and failed. In 2000, Gray added affirmative, control, and cooperative sentences.

Studies vary in the extent to which they have observed the ratio and in which version of guidelines they have followed. Crozier and Tincani (2005), Hutchins and

Prelock (2006), and Rogers and Myles (2001) did not observe Gray’s ratio; Adams,

Gouvousis, VanLue, and Waldron (2004) did observe Gray’s ratio in their story;

Hagiwara and Myles (1999) observed the ratio in only 1 out of 3 stories. Appendix B, column 17, provides additional details of studies’ adherence to the ratio.

Guideline 8. Guideline 8 recommends tailoring the story to the ability of the child, but ability probes, via comprehension checks, were limited to 14 studies (Appendix

B, column 19). In some studies it appears that the guideline may have been compromised by peers having provided answers to comprehension questions. For example, Ozdemir

(2008, p. 82) reported that “if the target child did not correctly answer a question, the peer was given an opportunity to provide the correct response.” A number of studies use standardized assessment protocols (Appendix B, column 5) to ascertain student’s overall ability or expressive and receptive language ability, but did not relate the baseline tests to the comprehension level of the story.

Guideline 9. One of the most controversial changes to the guidelines was the decision to include pictures, in 1998 (as long as they neither distract nor diminish student ability to generalize beyond the situation depicted; Gray, 1998). This change was made in response to research conducted by Swaggart and Gagnon (1995) and Kuttler and

Myles (1998) that suggested that students benefited from the inclusion of pictures. The addition of pictures, however, complicates the issue of trying to determine the efficacy of

SS™, by inviting a potential confound, especially when many authorities have emphasized the importance of the pictures in their own right (e.g., Attwood, 1998;

Grandin, 2006) and their contribution to the effectiveness of SS™ (Moore, 2004). The most frequently utilized visuals: Picture Exchange Communication Symbols (PECS),

Boardmaker, and Mayer-Johnson’s Picture Communication symbols are already endorsed as promising interventions for students with autism. Grandin (1995) too emphasized the importance of pictures for people with autism who tend to be visual learners. Pictures

31 may present information more directly and explicitly to individuals with autism. An illustration can convey specific, relevant, and sometimes abstract (e.g., prepositions) concepts without utilizing complex verbal processing strategies. Kunce and Mesibov

(1998) asserted that all kinds of visual aids, including written task directions, written cues, maps, pictures, handouts, and checklists provide students with autism with a lasting, visual reminder and are more effective than instructional languages and other presentation styles. Appendix B, column 18 “Illustrations” details authors’ use of visuals

(dates are cited in column 17).

Notably, some authors avoided using pictures in order to isolate the effects of

SS™ (Norris & Dattilo, 1999; Rowe, 1999; Scattone et al., 2002; Scattone, Tingstrom,

& Wilczynski, 2006). While the attempt at such research represents a positive endeavor, various methodological flaws further limit the ability to isolate the effects on account of additional variables contained within the SS™. For example, Scattone et al.

(2002) targeted behavior and included unauthorized teacher prompts as an additional variable; Rowe’s case study did not use an experimental design; a study by Norris and

Dattilo (1999) that used SS™ as the sole intervention reported no change in participant’s social interaction. Therefore, examining these studies in isolation fails to endorse the importance of SS™.

Guideline Summary

Although most authors purport to follow guidelines many deviations undermine the relevance of the most significant aspect of SS™. The recommendations supporting guideline 1 have either been disregarded, or not described, by the majority of studies.

Guideline 4 fails to distinguish the specific characteristics of SS™ from a generic story as traditional stories are typically written in third person and personal accounts are written in first person. Furthermore, several studies yield positive findings regardless of whether the ratio is followed (e.g., Crozier & Tincani, 2005; Hutchins & Prelock, 2006; Swaggart

& Gagnon, 1995). In effect, there are indications that the relevance of Gray’s specific guidelines may be questionable.

The next section presents further problems in demonstrating the efficacy of

SS™ particularly within the required scientific context. In addition to the potential confound already introduced by pictures, several other confounds are highlighted in the following section.

Confounds

The search for empirical support for SS™ interventions is further complicated by use of SS™ in conjunction with other interventions (Reynhout & Carter, 2006).

Reynhout and Carter’s meta-analysis identified only two studies as using “no additional strategies” (e.g., Brownell, 2002; Kuoch & Mirenda, 2003) yet failed to directly address the role of other strategies they had incorporated (e.g., Brownell’s study refers to “rewards that may result” [2002, p. 132] and Kuoch and Mirenda [2003, p. 223] incorporate negative verbal feedback [e.g., ‘No cheating,’ ‘Don’t hit your brother’] contrary to the positive spirit of SS™). In some cases there were unintended staff prompts despite the staff being aware of the intervention (Scattone et al., 2006). For example, Barry and Burlew’s (2004) study incorporated several other strategies including task analysis, priming, and corrective feedback, and authors concluded “it

33 was not surprising that an intervention that incorporates many empirically based practices was effective” (p. 49). Swaggart and Gagnon’s (1995) response cost intervention was the theme of their SS™ for a student’s aggression. In this study the

SS™ was entitled “How Can I Earn A Cola?” and the student was issued with a cola token that could be exchanged for cola. However, if she displayed aggression, the cola was taken away. In their recent study, Reynhout and Carter (2008) used an ABC design to evaluate the effects of SS™ on the targeted behavior of looking at a storybook during group reading time. In this study, phase C incorporated teacher prompting which authors referred to as a possible confound. The authors however concluded that the study “addressed some methodological flaws in previous research, notably in correctly constructing the SS™ and minimizing confounding risks from other interventions” (p. 172).

Many studies have failed to account for the confounding effect of extra time and adult attention, especially where attention may be a function of the target behavior.

However, a study by Dodd et al. (2007) addressed this issue by using a non-SS, as a placebo in order to control for receiving adult attention, and reading before the activity.

Similarly, Bäckman and Pilebro (1999) reported that extra preparation time in itself may have contributed to improved results in a study that used SS™ to help a 9-year-old boy prepare for dental treatment.

There are very few studies where the SS™ was the sole variable (Bledsoe,

Smith Myles, & Simpson, 2003; Briody & McGarry, 2005; Dodd et al., 2007; Lorimer,

Simpson, Smith Myles, & Ganz, 2002; Norris & Dattilo, 2007; Reynhout & Carter,

2007; Sansosti & Powell-Smith, 2008; Toplis & Hadwin, 2006), although each of these studies incorporated pictures. Rowe’s (1999) intervention study was the only one identified where SS™ was the sole variable and pictures were not included, all other

SS™ were combined with additional interventions (Appendix B, column 18). In some cases SS™ was added to ongoing interventions such as speech-language, and occupational therapy (Lorimer et al., 2002). Therefore, the difficulty of extricating

SS™ clearly presents problems in relating success to the SS™.

Overall, there are very few studies where SS™ can be identified as the sole variable; this does not necessarily undermine the SS™, rather, it emphasizes the difficulty of extricating the SS™ for evaluation. The next section provides an overview of experimental design flaws where the same issue of how to link the SS™ intervention to the outcome prevails.

Research Design

Thirty-three of 34 SS™ interventions were reported to be at least partly successful in achieving their goal. However, empirical evidence demonstrating that changes would not have occurred without SS™ is limited. Sansosti et al. (2004) evaluated SS™ interventions by research design: AB, ABAB reversal, ABAB reversal with variations, and multiple baseline, and discovered (as noted previously) that across designs, SS™ showed limited evidence of being effective in reducing target behaviors and showed no evidence to support acquisition of new skills. Sansosti et al. concluded that “due to a lack of experimental control, weak treatment effects, or confounding treatment variables in the reviewed studies, it is difficult to determine if Social

Stories™ alone were responsible for durable changes in important social behaviors” (p.

196).

AB Design

Although AB designs have been utilized frequently in SS™ research, several weaknesses limit the use of such data for determining an evidence-based relationship.

First, the AB design can not determine a functional relationship between treatment and outcome variables. Second, AB designs are “plagued by threats to internal and external validity” (Delano & Snell, 2006, p. 39). For example, generalizability is extremely limited, additional variables may have a confounding effect and be impossible to extrapolate, and also demonstrating that the treatment effect makes a difference is difficult, unless some repeated measures are used. Third, there is a lack of information about the course of the target behavior without the intervention.

Despite their weaknesses, AB designs do have several advantages that likely contribute to their use within applied settings. Specifically, AB designs provide information that changes in behavior are not a function of the passage of time. In addition AB designs may be the only practical option available to educators. Seven of the SS™ interventions reviewed utilized an AB design (Appendix B, column 6).

Reversal/Withdrawal Designs

Reynhout and Carter (2007, 2008), Agosta, Graetz, and Mastropieri (2004), and

Kuoch and Mirenda (2003) extended the AB design by incorporating reversal or additional treatment phases to enhance internal validity. Return to baseline, or withdrawal of intervention introduces an ethical dilemma of whether or not to withdraw a

36 treatment that appears beneficial. Swaggart and Gagnon (1995) used an ABA design but decided not to return to baseline because they suspected undesirable behaviors would re- emerge and consequently forfeited design strength.

Strengthening ABA with an additional treatment increases internal validity but ethical issues remain. Using an ABAB design the researcher can be more certain that changes in the DV are attributable to the IV from repeated exposure although this does not rule out remote, naturally occurring variations (Tawney & Gast, 1984). Appendix B, column 6, lists authors who used ABAB designs. All authors used the intervention to modify behavior, which rests on the assumption that behavior can be brought back to baseline, wherein several ethical dilemmas are revisited. For example, manipulating variables that result in behavior deterioration is ethically questionable, especially when this involves removing a beneficial treatment. As yet, little is known about maintenance of skills in the long term. Appendix B, column 10 indicates that very few studies incorporated maintenance probes and theses were limited to short term. As yet there is no scientific evidence that acquired skills are retained in the longer term so ethical problems prevail.

Multiple Treatment Designs

An ABAC, multiple treatment design, measures baseline before each treatment.

Treatments B and C are different, which allows for separate exploration of the variables.

Brownell (2002) used an ABAC multiple treatment design for music and non-music combinations of SS™ to see whether either treatment was more beneficial. However, since where treatment B is SS™ and C is SS™ with music, the order of treatments might

37 bear on the results. To overcome problems with order, Brownell used a counterbalanced design of ABAC/ACAB where students received the treatments in a different order. By counterbalancing, Brownell’s design isolates SS™ as a sole variable to balance against

SS™, which is musically accompanied. The study yields mixed results whereby there was no significant difference in outcomes for the B and C conditions. Crozier and

Tincani (2005) used an ABAC reversal design to isolate the SS™ and SS™ with verbal prompts and found that SS™ with additional prompts further reduced disruptive behavior. The ABAC design does not however establish a functional relationship between B and C conditions. Kuoch and Mirenda (2003) used an ACABA or multiple treatments with return to baseline design to isolate effects of interventions with favorable results.

Multiple Baseline Designs

A multiple-baseline design shows the functionality of the intervention by demonstrating that the intervention apparently produces the same kind of behavior change across a variety of behaviors of the same subject within a given setting, or across a variety of settings for the same behavior of a single subject, or across a variety of subjects displaying the same behavior in the same setting or more controversially, various combinations of these (Horner & Baer, 1978, p. 257).

A review of extant literature reveals five studies that used multiple baseline across participants (e.g., Dodd et al., 2007; Ozdemir, 2008; Sansosti & Powell-Smith, 2006;

Scattone et al., 2002; Scattone et al., 2006) and one study, Delano and Snell (2006), used

38 a multiple-probe design (i.e., a variation of the multiple baseline design) across participants.

Sansosti and Powell-Smith’s (2006) multiple baseline data demonstrate

“immediacy of effect” (Kazdin, 1982) upon implementation of the intervention but the students who received the treatment, after the first participant, did not have stable baselines. Tawney and Gast (1984, p. 227) recommended that the intervention should be applied “only when all baseline data series maintain acceptable stability in level and trend.” The second student’s data showed an already therapeutic trend during baseline and the results for the third student were highly variable, thus, the authors advised cautious interpretation. Results for the first and second participant were interpreted as favorable but it was impossible to know whether the SS™ influenced the dependent variable for the second participant. Despite using a more robust design, the introduction of treatment without a stable baseline compromised the results.

Scattone et al. (2006) showed similar findings. There is an increase reported for one participant with a percentage of non-overlapping data (PND) of 89% (i.e., 1% below the highly effective cutoff), a questionable outcome for one participant (i.e., 1% from the fair outcome cutoff), and an unreliable treatment (Scruggs, Mastropieri, Cook, &

Escobar, 1986). Tawney and Gast (1984) advised that the intervention should be applied

“to a new subject only when criterion-level responding is demonstrated by the preceding subject” (p. 257), but there was little evidence that the first student was responding to the intervention (i.e., a single rise in social interactions during one session and two

39 subsequent increases). The subject’s social interactions were decreasing and had returned to baseline (0%) when the intervention was introduced to the second participant.

Dodd et al. (2007) reported gains in 2 students with a diagnosis of PDD-NOS in a study that used a multiple baseline design across behaviors and a multiple baseline across participants. One student decreased the amount of excessive directions that he was accustomed to giving to his brother and increased compliments for his brother’s ideas.

The other participant in this study also increased compliments. There was an immediate and significant increase in compliments for the second student but the increase was not sustained. This study does not accommodate for long-term effects and the intervention was limited to 8 sessions or less.

Scattone et al. (2002) found that the SS™ was effective across all participants.

The baseline was already moving in a therapeutic direction prior to the intervention to reduce shouting in the case of the third student. Authors discussed the possibility of the story (about chair tipping) for one student reducing the frequency of behavior in the other student, who was in the same class, at baseline although the stories targeted different behaviors (i.e., when the other student modeled improved behavior, this may have impacted the behavior of the other student). Tawney and Gast (1984) emphasized that subjects in a multiple baseline design must be functionally independent. Delano and

Snell (2006) used a multiple probe across participants design. Frequency and duration of social engagement showed increases across all participants, including the target subjects.

Ozdemir’s (2008) study also demonstrated significant gains in social engagement across three participants. A significant weakness in credibility of Ozdemir’s study is that there

40 were no measures undertaken to establish whether the intervention was socially acceptable to teachers or parents (i.e., social validity) or strategies adopted to confirm that the treatment was implemented as designed and intended (i.e., treatment integrity).

Design Strengths

Even the most robust designs cannot dictate the cooperation of the participant; however, many studies incorporate other strategies that add strength and increase the credibility of their results. Appendix B, columns 22, 23, and 24, show which authors incorporated measures of social validity, treatment integrity and interobserver reliability.

Interobserver reliability is defined as the extent to which “the observers agree that target behaviors occurred or did not occur” (Tawney & Gast, 1984, p. 88). Some studies (e.g.,

Delano & Snell, 2006; Sansosti & Powell-Smith, 2008; Scattone et al., 2006) ensured that treatment was blind. Additionally, some authors indicated that observers were highly trained (Sansosti & Powell-Smith, 2008; Scattone et al., 2006) and that there was ongoing collaboration either with the school team or family (Sansosti & Powell-Smith, 2008;

Scattone et al., 2006). Additionally, some studies conducted maintenance and generalization checks (Appendix B, column 10).

Dodd et al.’s study (2008) was the only study that incorporated a “non-social” story placebo in the baseline condition to control for receiving adult attention. Authors also addressed intervention acceptability with both parents and children. Scattone et al.

(2002) used Intervention Rating Profile-15 (IRP-15, Martens, Witt, Elliott, & Darveaux,

1985) to evaluate teacher acceptance.

Conclusion

In conclusion, changes in the guidelines, misinterpretations of guidelines, differences in delivery of the intervention, confounds, design flaws, and other described limitations, all appear to diminish the importance, role, and contribution of the SS™ guidelines to the success of the intervention. The literature reviewed clearly shows the difficulty in attributing success solely to SS™ in many of the studies. Extant studies highlight the need for further research with tighter experimental control and more rigorous practice. All thirty-four reviewed studies recommend that additional research must be conducted to scientifically validate SS™.

Success of SS™ may not depend upon one single standard or specific adherence to a set of guidelines. Because the extant literature has demonstrated that positive outcomes can be gained when deviating from Gray’s guidelines, it is difficult to ascertain which elements impact the positive findings. In fact, positive outcomes from studies that do not follow the SS™ guidelines diminish the importance of the distinction between

SS™ in itself and any other traditional kind of narrative. Also factors in the delivery of the SS™ may have been overlooked, namely in the consistency of the implementation process (i.e., visual presentation; auditory reading; 1:1 attention and repetition through daily the reiterations). All of these strategies may offer benefits. As a result investigations examining the outcome of using a simple narrative that does not follow a prescribed formula appear to be warranted.

Purpose

Much of the literature describes SS™ interventions that deviate from Gray’s guidelines. Other studies that have followed some of the guidelines do not demonstrate significant evidence of effect (Norris & Dattilo 1999; Rowe, 1999; Scattone et al.,

2002; Scattone et al., 2006). Not only is there very little evidence to relate the SS™ structure to the success of narrative interventions, but also, due to the plethora of variations, misinterpretations, confounds, and threats to validity, it is almost impossible to empirically validate Gray’s SS™. Although the majority of the extant literature reports benefits of using SS™, more rigorous research that delineates if the prescribed guidelines are necessary is warranted. However, to date there are no extant studies that have examined the effectiveness of an approach that has intentionally set out to deviate from Gray’s guidelines.

The aim of this study is to continue to build on current research and extend the current line of enquiry to investigate whether a difference in outcomes exists when using a simple narrative strategy that is not confined to any guidelines; that is, a study that does not conform to the sentence ratio that defines SS™ or presentation guidelines.

If the guidelines are eliminated altogether then evidence of the importance and potential success of the narrative can be substantiated. The purpose of this study is to explore the contribution of the simple narrative as an intervention for students with autism.

Based on exploration of current literature, it is hypothesized that utilization of a social narrative that does not conform to a sentence type ratio will yield positive

43 findings (i.e., participants will demonstrate an increase in social initiation skills compared with baseline skill levels). It is further hypothesized that treatment effects will be maintained for at least two weeks post intervention. The study also expands on the existing body of research by: (a) conducting longer term maintenance checks, (b) exploring and gathering data on generalization, (c) examining social validity, (d) checking for procedural integrity, and (e) exploring the impact of the narrative used without additional strategies such as pictures or prompts.

CHAPTER II

METHODOLOGY

This section provides an overview of how the study was conducted. Participant selection criteria, research design, and procedures and methods for data collection and analysis are also outlined.

Participants

The participants in this study were three males with a medical diagnosis of autism. Participants were aged 5 years and 10 months, 8 years and 8 months, and 9 years and 9 months (average 8 years and 1 month) at the start of the intervention. Participants will be referred to as Caleb, David, and Charles, respectively. All students attended the same school in Northeast Ohio.

Individual Participant Information

Caleb

Caleb was a Caucasian 9 year, 9-month-old boy when he was observed during the summer immediately prior to the study commencing. He attended elementary school where he participated with students in a special education classroom for two sessions per day to work on speech and language skills and specific curricular activities. Caleb spent the remainder of his school day with typical peers in his regular education fifth grade setting. Caleb did not receive any special educational paraprofessional support throughout his school day. Caleb was a member of a triplet birth and has one brother and sister. Neither sibling exhibited any characteristics of Autism.

44 45

Caleb received a medical diagnosis of autism at the age of 3. Caleb’s records show an IQ 69 standard score on the Kauffman Assessment Battery for Children. Caleb usually only spoke to express wants and needs but frequently used complex sentences of up to 7 words. Caleb made eye contact but did not sustain it. He was echolalic and often repeated verbal routines that were non-directed. Caleb was able to request preferred items but did not initiate interaction beyond expressing wants and needs and did not ask students to play. Caleb demonstrated very rigid behaviors and had strong preferences for specific activities (e.g., he liked to color, write letters of the alphabet, or cut).

David

David was a Hispanic 8 year, 8-month-old boy when the study commenced.

David attended elementary school and was in fourth grade, where he received services in a self-contained setting throughout the day except at lunchtime. David was supported by an educational support paraprofessional (ESP) throughout his whole day. David had no siblings and lived with his recent adoptive parents who had very little information about his past. David was initially diagnosed with autism in 2005, immediately before his fourth birthday. The Director of Student Services reported that there was no valid IQ measure on file. David was described as non-verbal but reportedly was able to make requests using an AAC device when in the classroom during the academic year.

David exhibited several rigid behaviors (e.g., spinning objects and looking upwards with a fixed gaze) and his teacher suspected that he had only been recently introduced to solid foods because he was accustomed to having everything, with the

46 exception of pizza, dipped in applesauce before he would eat it. David also liked to drink apple juice. David did not avoid eye contact.

Charles

Charles was a Caucasian 5 year, 10-month-old boy when the study commenced.

Charles attended the elementary school and participated in the special education classroom during the mornings. He also ate lunch in the classroom, and went to his regular first grade education class each afternoon after recess. Charles was individually supported by an ESP throughout his lunchtime, recess, daily transitions, and during his regular education afternoon time. Charles had one older ‘typical’ sister. Charles’ records do not indicate when his initial medical diagnosis of autism was made but he received an educational evaluation in his Kindergarten year and autism eligibility was determined.

The Director of Student Services reported that “there was no IQ measure on file.”

Charles avoided eye contact and gazed downward. Charles exhibited comprehension skills similar to those of same age peers when responding to staff but he seldom initiated interaction except to express wants or needs. Charles’ IEP stated that he was “easily distracted by sights, sounds and internal distractions.” Charles appeared to like going outside for recess and particularly enjoyed swinging. Charles enjoyed looking at books and listening to the teacher read aloud at circle time.

Settings

All boys were observed during their lunchtime periods so that the observations and interventions would cause minimal, if any, disruption to planned instruction and so that no additional transition or change was introduced. Caleb and Charles were observed

47 during their lunchtime recess period. Both boys attended recess in the school playground at the same time as their typically developing same-aged peers. The playground had several discreet areas that were joined by a path around the school. On one side, where all students exited the building after lunch, there were two swing sets and a climbing apparatus with space where students played kickball or basketball. On the other side of the school building there was a large open blacktop playground area and two surrounding

“wood chip areas.” One wood chip area had a climbing frame, monkey bars, and seats; the other had a larger climbing frame and slide connected by monkey bars to another play structure with a swinging metal bridge, climbing bars, and a tube slide. Immediately behind this structure was a 24-person teeter-totter with individual seats that moved up and down like waves. Another slide and structure stood at the other side of the teeter-totter. There also was an outdoor pavilion seating area.

David was also observed during the lunchtime period but he was observed indoors so he would be able to use an AAC device that could be recorded at his table. David initially spent his lunchtime with his ESP. David ate in a separate room without peers during snack and lunchtimes on account of reported “loud, agitated behavior; messy eating and grabbing other students’ food.” David was fed hand-over-hand by his ESP, although he was able to hold a spoon and bring it to his mouth, and ate apart from all peers. David did not have his Augmentative and Alternative Communication (AAC) device available to him during the lunch period. After he had had lunch David was taken back to recess in the school playground with another ESP.

Procedures

Recruitment

A meeting was arranged between the investigator and the district Director of

Student Services to seek consent for the study, to discuss the intervention goals and the multiple baseline, across participant, design, and share the recruitment criteria. The

Director of Student Services was asked to nominate potential participants based on the following inclusion criteria: (a) students had to have a current diagnosis of Autism

Spectrum Disorder based on DSM-IV-TR criteria; (b) students were eligible to receive special education services; (c) student’s Individual Education Program (IEPs) included goals in the area of social interaction; (d) students could communicate functionally, for example, students would need sufficient skills to initiate interaction (verbal or non- verbal) and possessed the receptive language skills to understand a simple direction. The

Director of Student Services also recommended that children attend the same school setting in order to minimize disruption to school programming.

Selection

The Director of Student Services consulted several teachers in the district to determine willingness to cooperate with the study. Two special education teachers volunteered and identified potential participants within their special education programs.

With consent from the district’s administration, preliminary observations of five students were conducted by the investigator during the four week summer autism program where the investigator worked as a volunteer (on a 3 day per week basis for 3.5 hours per day with staff regularly employed in the school district of attendance)

49 immediately prior to the fall when the intervention took place. Students were observed during the summer to determine whether they demonstrated sufficient comprehension skills to be able to benefit from a social skills intervention. Students were observed to establish that they could respond accurately to simple statements such as “Get backpack” or “Do you want a drink?” and to demonstrate the ability to request an item using gestures, symbols, or words.

Of the five observed, the three students selected for the study demonstrated varied communication skills but none of them were able to produce an unprompted and purely social initiation to another peer or adult, for example, students were not accustomed to communicating other than to express wants. The commonality amongst participants, and the salient criterion for inclusion in the study, was the deficit in initiating communication.

The sample was also selected based on convenience to the district. The fact that all students attended the same school classroom during the academic year minimized disruption to programming (by the study) and therefore the environment and teacher could remain constant.

Permission

Parents were contacted via the school special education teacher. Parents of all five students initially observed received a letter describing the aims and intent of the study and asking for their consent. Parents were invited to contact the investigator with any further queries. Following the initial consent letter, a further letter of consent to audiotape the children was issued to parents of the three children selected for intervention. The parents of the two other students were contacted by the researcher to

50 explain that the study would not take place at the school that their children attended at that time. Consent letters were signed. Child assent letters were not issued because of the difficulty communicating and describing future events to the participants.

Identification of Target Behaviors

Caleb. Caleb also played alone at recess. His mother reported that he appeared to enjoy playing with his siblings (i.e., they would initiate the play interaction) but that he did not have friends at school and she was aware that he did not play with other children in that setting. Caleb’s mother felt that he would benefit from being taught how to approach and interact with other students; however, Caleb’s special education teacher reported that Caleb appeared to be indifferent to whether he was involved with other students or not. Both students responded to typical peers if approached, but did not initiate nor sustain interaction with other students. Target behaviors for Caleb were approaching students and initiating interaction such as indicating “I want to play” as well as spontaneous requesting “push, higher.” Commenting to other students was also a target behavior.

David. At lunchtime David was fed by a paraprofessional in a separate room.

David cried and appeared very frustrated and uncomfortable throughout this time. David was not using any Augmentative Alternative Communication (AAC) device when at lunch so had no effective means to communicate appropriately although he could indicate when he wanted more food (applesauce) by pointing. David cried often throughout the lunchtime and made no other utterances. Target behaviors for David were to use his

AAC to initiate a socially appropriate communication response such as “thank you”

51 without prompts. (However, significant preparation had to be done pre-baseline so that

David could utilize an AAC).

Charles. Charles’ mother, his special education teacher, and ESP reported that

Charles always played alone. Charles’ special education teacher reported that Charles appeared to want to play with other students because he had sometimes pointed to other students and said their names. However, Charles did not directly approach peers that he appeared to want to play with. Typically Charles sat alone on the swing at the end of the swing set, away from other students, and swung throughout the recess period while being observed by his ESP. Charles’ IEP stated that “he had difficulties remaining engaged in group activities.” Charles’ IEP also stated that Charles was able to “express immediate needs and wants” and discussion with his special education teacher revealed that, other than needs and wants, Charles did not initiate interaction with staff or peers. The target behaviors for Charles were to gain peer attention and to initiate requests for peers to play with him. Requests could be made verbally or using the physical gesture of tapping a student on the shoulder to gain attention.

Dependent Measures

Dependent measure for Caleb. The verbal initiations had to be directed to an adult or peer. This was determined by whether Caleb approached and oriented his body towards somebody. For example, if Caleb shouted “I want to play” and was alone in an area of the playground then it was an undirected utterance and not counted. Requests, such as “higher” to be pushed higher on the teeter-totter also required a recipient, so only requests that were clearly directed at a recipient could be counted, that is using eye

52 contact or body orientation that would suggest that the request is directed at someone.

Social comments were counted if they were spontaneously made in the presence of an audience. No comments that were prompted by a peer or staff member were counted.

Dependent measure for David. David knew how to initiate using a pointing gesture to indicate that he wanted something. He was taught to use his AAC board to request using a tangible food reinforcer. The objective for David was to use a socially appropriate phrase after he had received the reinforcer. A “thank you” phrase was placed on his AAC board with a Boardmaker icon that he needed to voluntarily press after he received his food item. The purpose of an initiated “thank you” was to encourage David to use a phrase that did not give him a tangible reward. David’s use of ‘thank you” would only count if it was used after he had received his food item and when it was used correctly. If “thank you” was pressed at the time of requesting food it was not counted.

No comments that were prompted by a staff member were counted.

Dependent measure for Charles. Charles’ initiations counted when they were clearly directed to a peer, that is, Charles needed to be in close proximity to a peer with his body oriented towards that peer or using eye contact. Initiations that involved correctly calling a student by name were counted. Initiations that involved tapping a peer on the shoulder were also counted regardless of whether Charles was able to generate a verbal request afterwards. No comments that were prompted by a peer or staff member were counted.

Dependent variables. The dependent variables were based on the target behaviors. These were identified through observations of the participants in their regular

53 settings and informed by parent and teacher reports as well as the goal statements in their

Individualized Education Programs (IEP). These are shown in Table 1 below for Caleb,

David, and Charles respectively.

Table 1

The Dependent Variable for Caleb, David, and Charles

Student Dependent Variable (IEP goals are added to illustrate similarities)

Caleb Current IEP goal:  Verbal initiations to include phrases such as, “I  Needs to improve self-help skills in order to be want to play” independent in activities appropriate to his age.  Spontaneous requests directed at someone such Objectives: as to push “higher,” “stop”  Will verbally ask a friend to play with one  Comments such as “fallen” when they have prompt* clearly been directed at someone.  Will engage in a reciprocal activity with a peer through 3 turns with a prompt Responses to questions will not be counted Utterances to self will not be counted Prompted actions will be discounted

David Current IEP goal:  Use of a talk board to state “thank you”  To develop social skills that are age appropriate in order to interact with his peers Prompted actions will be discounted Objective:  Will eat snack and/or lunch with typical peers.

Charles Current IEP goal:  Independently initiated verbalizations and  To develop social skills and increase peer responses to other students (e.g., “Hi, Eddie,” interactions “Will you play with me?” “Hi, Joanna”). Objective:  Independently initiated taps on the shoulder will  To initiate a greeting with a peer be counted.  To respond to his name being called by glancing at or verbally acknowledging the Prompted actions will be discounted speaker

Design and Preparation of Interventions

Research Design

The purpose of the intervention was to explore the efficacy of social narratives that do not conform to SS™ guidelines. A multiple baseline across participants design was used to examine the IV/DV relationship. According to Horner and Baer (1978), the multiple-baseline design authenticates functionality of the intervention by demonstrating that the same behavior change will be produced across the three subjects in the same setting.

Advantages of multiple baseline across participants, designs are that they are easy to conceptualize and implement; that they can be used to demonstrate efficacy without intervention withdrawal, and thus there are no ethical issues with removal (Horner &

Baer, 1978). Horner and Baer further recommended that outcome objectives need to be identified before the intervention and that the intervention should only be introduced when acceptable stability levels are reached during the baseline phase. Similarly, the intervention should only be introduced to participants two and three respectively when criterion level responses are exhibited in the previous participants. Accordingly, the outcome objectives were identified in advance of the study.

The special education teacher and the speech and language pathologist were informed about the aims of the study but, apart from the director of Student Services, no other staff member knew what the focus of the intervention was so that threats to experimental control were minimized.

Materials

Social narrative. A social narrative served as the independent variable and was used for each participant. Each of the narratives was constructed to focus on individual participants’ target behaviors. Table 2 shows the social narratives that were used for the three boys compared with an example of how a narrative (e.g., Charles) would have been written as a SS™. The SS™ and the social narrative in Table 2 were both checked for validity using The Social Story™ Validity Checklist (Appendix C; Sansosti, 2005) to confirm that the SS™ conformed to guidelines and that the social narrative did not. The social narrative was, therefore, constructed as a narrative with less contextual information and no additional perspective information.

Table 2

Example of Social Narrative

Social Story™ Social Narrative

Playing Charles At school many children play games on the At recess I will play with a friend. playground at recess. (Descriptive) I will find a friend. Usually, playing is a lot of fun. (Perspective) I will tap a friend on the shoulder and ask, I will try to ask someone to play. (Directive) “Hi, will you play with me?” Playing is a fun thing to do. (Affirmative) I will say, “Hi” to five friends today. If I ask to play with someone they may play with me. (Cooperative) Caleb Playing with others is fun for them. (Perspective) At recess I will ask a friend, “Will you play with me?” * Initial story would have already been constructed I will play on the teeter-totter, slide or to confirm what participant does well. playground and say, “Will you play with me?”

David When I want more applesauce I will say, “I am hungry, more please.” When the teacher gives me the applesauce, I will say, “Thank you.”

The narratives were handwritten (approximately 1cm print) and aligned (as above) using a black marker on the inside of a folded 28cm x 21 ½ cm piece of plain, white, unlined paper (21 ½ cm x 14 ½ cm). The narratives were not typed as recommended in the SS™ guidelines (see Appendix D). There were no visuals of any sort to accompany the narratives. David had a Boardmaker icon “thank you” on his AAC for visual discrimination. The special education teacher and speech and language pathologist reviewed the narratives and felt that they were appropriate to the comprehension levels for each student although the level of understanding for David was more difficult to determine. No additional formal measures of comprehension were taken.

Measures. Participant utterances and initiations were measured using a digital audio recorder. The digital recorder was accurate and was checked prior to each session.

The same instrument was used for all sessions, and all data for each participant were collected following identical protocol described below. The audio recorder was used to record participant utterances. David’s initiations were verbalized by the AAC and recorded by the audio recorder. Participant utterances were supported by explanations by the investigator (e.g., where the participant is and what he is doing; whether his body is oriented towards somebody, whether the participant was talking to himself) since the explanation would help determine whether appropriate social interaction was taking place. Investigator commentary supported the analysis process. A video recorder was not permitted because of confidentiality issues (given the number of children who would appear on the tape) and also because participants Caleb and Charles were in constant

57 motion. The investigator remained in close proximity to the participant during each recording session (i.e., within 1m).

The digital recorder remained on the record setting throughout each session. Each recording started and ended at the same time each day. However, due to scheduling variations (e.g., inclement weather, later lunch, announcements), the duration of recording sessions varied. Utterances were counted as frequency and reported as rate, that is, the number of utterances that met criteria to be counted as an initiation was divided by the duration of the recording interval in minutes. Caleb’s and Charles’ recess sessions were taken with regular education peer groups and counted from the time they exited the building for recess until the investigator indicated on tape that the session had ended. No unrecorded utterances that occurred before or after the recording session were counted. If the digital recorder had to be switched off for any reason, the session was terminated and discounted. An investigator commentary of Charles’ proximity to other students was also recorded and analyzed as supporting anecdotal evidence. David’s session began immediately after the narrative reading and when his lunch was placed on the table in front of him (i.e., where opportunities to initiate interaction commenced) and ended when the investigator indicated that the session ended.

Inter-Observer Agreement

The investigator also spoke into the recorder during the recording sessions to identify any confound that the recorder could not capture such as a verbal of visual prompt or cue. The recordings were downloaded onto a computer immediately after each session. One third (33%) of recordings for each student, across each condition, was

58 analyzed for inter observer agreement with a speech and language pathologist.

Recordings were replayed to check for agreement as to the nature of the utterances as they related to the DV. The investigator and observer listened to the recordings and coded ‘more please’ (MP) and ‘thank you’ (TY) as the recording played so that they could observe the strict order of the utterances. For example, in David’s case observers needed to note whether phrases were made after food had been received. If food had been received and David pressed “thank you” before pressing his next “more please” this was accepted as correct. The TY correct were counted.

The same inter-observer procedure was followed for all three participants.

Caleb’s utterances were coded as initiations (IN), responses (RE) or prompts (PT).

Prompts were noted on recordings by the investigator as well as comments such as

“undirected” when he was clearly not communicating with a peer or adult. Investigator narrative was also used to indicate Charles’ proximity to others and whether he tapped a peer on the shoulder. The investigator indicated where there had been any unauthorized prompts during the recording (e.g., where a member of the playground staff, who was blind to the focus of the intervention, approached the participant and suggested he play with someone).

To calculate the percentage agreement the observers added the sum of codes that were agreed upon (agreed) and the sum of those that were not agreed upon (disagreed).

The sum of the agreed was then divided by the sum of the agreed and disagreed. Inter observer agreement was at 94% for Charles; 100% for David, and at 88% for Caleb.

Treatment Integrity

A checklist was maintained to show the date and time of the narrative reading

(twice per day) for each participant; that the recorder was switched on; that the participant was in the relevant instructional setting; that the story had been read twice by the investigator; and that the story had been read accurately with no interruptions.

Social Validity

At the end of the study the special education teacher was asked to complete an

Intervention Rating Profile (IRP-15; Witt & Martens, 1984) for social validation of the narrative intervention. Parents were also asked to complete the same form by mail

(Appendix E).

Pre-Baseline Preparation

Additional preliminary work had to be done to prepare David for the intervention.

Several variations were made: first, David was introduced to the classroom environment for lunch; second, David ate lunch with the investigator and not the ESP; third, David was not fed hand over hand. These variables are acknowledged as potential threats to internal validity. David’s intervention was designed to incorporate the more familiar phrases that were already on his talk board. However, David’s only experience with the board had been hand over hand and so prior to intervention David had to be taught how to use the board to make a request. David had not been given opportunity to communicate or express preferences when fed by his ESP.

David was taught to use the talk board to make a request and applesauce was used as a reinforcer. When David had learned how to initiate a request for food using his

60 board he was consistently given a reinforcer. This was done for several days until David became accustomed to using the board. The independent variable for David was the second communication “thank you” that was added to encourage socially appropriate responding using his board. There was no contingent reward that David received. David was required to initiate a “thank you” with no extra motivator that could be a confounding variable.

An observer introduction phase of one week commenced prior to the baseline data collection phase, to reduce reactivity to the observer and being observed (Kazdin, 1979).

During the observer introduction phase the investigator stayed in close proximity to each participant, carrying the digital recorder in exactly the same way as was intended for the baseline and intervention phases that followed. The observer introduction phase occurred during Charles’ and Caleb’s recess times and during David’s lunchtime to be consistent with intervention phase times.

Baseline Phase

The baseline data collection phase commenced immediately after the observer introduction phase. During baseline data collection phases, the investigator recorded all participant initiations (as described in Table 2). Each participant had a different intervention time and so no recording times overlapped. The recorder was be switched on when Charles and Caleb exited the school building and stepped into the playground.

The recorder remained on throughout Charles’ and Caleb’s recess times and throughout

David’s lunchtime. Since a digital recorder was used to record utterances there was one investigator following the students. Baseline data were shared with the special education

61 teacher. Data were plotted on a graph and visually inspected for stability. When at least three data points were stable, and did not show a therapeutic trend (at baseline), the intervention was be introduced to participant one. Baseline data were also collected in one other unstructured setting for Charles and Caleb and during snack time for David.

These data were used as baseline generalization probes.

Intervention Phase

When at least three stable baseline data points had been collected, the intervention was introduced to participant one. The intervention was only introduced to the second and third participants when criterion response levels had been met for the preceding participant, that is, when at least three therapeutic data points had been obtained that did not overlap with baseline data. The intervention was then introduced to participant two and similarly, after three stable data points had been recorded, the intervention was introduced to participant three.

During the intervention phase the investigator read the narrative to the participant immediately prior to the target situations described. Each participant was asked three questions immediately after the reading of the story from the first day onwards to ensure comprehension. The investigator then read the narrative one more time before accompanying the student to the playground or setting down his lunch tray. The digital recorder was switched on at the exit door during Caleb’s and Charles’ respective intervention phases. When each participant had three stable therapeutic data points plotted on their intervention, one additional phase was added to explore whether skills have been generalized.

Follow up Phase for Maintenance

After the intervention phase, maintenance data were collected for one session per week, for the next two weeks, and one final session for long term maintenance was conducted more than six weeks after the intervention for each student.

Data Analysis

Changes in level, variability, and trend were inspected visually during baseline and intervention phases. After the intervention had been completed, data were then analyzed to determine whether levels of social initiation had increased in accordance with the hypothesis that students would increase social skills and maintain the increase in skill levels for at least two weeks post intervention. The data were graphed using an Excel spreadsheet so that baseline data could be compared with intervention and post intervention phases. Data were inspected to determine whether the intervention coincided with any abrupt change in the first data series, while the other baselines remained stable (Tawney & Gast, 1984). The Nonoverlap of All pairs (Parker &

Vannest, 2009) was also used to calculate the effect size during A and B phases. The

Nonoverlap of All Pairs is an index of the data overlap between the A and B phases.

CHAPTER III

RESULTS

This chapter explores the findings of the study in the context of the research questions and hypotheses generated through the review of literature in the first chapter.

The overarching purpose of the study was to explore whether there would be a difference in outcomes when using a simple narrative strategy that was not confined to any guidelines such as the sentence ratio that defines SS™ or Gray’s presentation guidelines.

Two hypotheses were proposed, first, it was hypothesized that the simple narrative would be associated with positive outcomes and result in an increase in student initiations for the three participants; second, it was hypothesized that treatment effects would be maintained for at least two weeks post intervention.

The study also aimed to expand on the existing body of research by (a) conducting longer maintenance checks, (b) exploring and gathering data on generalization, (c) examining social validity, (d) checking for procedural integrity, and

(e) exploring the impact of the narrative used without additional strategies such as pictures or prompts. The results are described below and reviewed more thoroughly in the Discussion chapter that follows.

Outcomes of the Social Narrative Intervention

The study aimed at increasing social initiations for three male participants aged 5,

8, and 9 using a social narrative that did not conform to Gray’s guidelines (2004). Data were collected for 15 to 20 minute sessions each day during each phase of the study.

Figure 1 shows the rate of initiations for each student during the baseline, intervention,

63 64

Caleb

Baseline Intervention Maintenance 0.4

0.2

initiations of Rate 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

Initiations of ate

R Days

David

1 0.8 0.6 0.4 0.2 0 * 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 Days *no AAC available Rate of Intitiations of Rate aavailabledevice

Charles

0.3

0.2

0.1

0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

Initiations of Rate Days

Figure 1. Social narrative interventions

65 and maintenance phases. The rates were calculated by taking the number of utterances that met criteria, to be counted as initiations, and divided by the duration of the recording.

The numbers were calculated as rate because, although the daily intervention times were arranged by the students’ fixed lunch and recess schedules, the times were subject to variation e.g., time spent eating; medication; weather conditions and other unforeseen occurrences. The duration of the recording time, therefore, had to be adjusted to accommodate for any variation in the amount of time offered for students to exhibit behaviors. The final outcome of this study was analyzed with two evaluation methods: visual inspection of the graphs and The Nonoverlap of All Pairs (NAP).

Visual Inspection of Graphs

Graphs were visually inspected for trends and differences between phases and mean rates were calculated to reflect the mean increase between A and B phases. In figure 1 the baseline phase shows the number of initiations at baseline; the number of initiations for each student during the intervention phase, and the number of initiations during the maintenance checks. The data confirm that initiations were lower or at zero during baseline than the initiations which increased for all participants during the intervention phase. Initiation increases continued during maintenance except for David.

The maintenance phase is addressed later in this section. Generalization issues are also described below.

Caleb

Caleb was introduced to the intervention first. Observer reactivity was accommodated for during the week prior to the start of the study for all participants as the

66 researcher was present during that time, allowing the subjects to get used to her. Baseline data were collected prior to the intervention being introduced to each participant. After a stable baseline was established the intervention was introduced. Figure 1 shows that the mean rate of initiations for Caleb at baseline was .0015. Initiations for Caleb included commenting where comments appeared to be directed towards a listener. During the intervention phase Caleb’s mean rate increased to .82. Caleb reiterated the phrase “Will you play with me?” as written in his story. Caleb’s initiations increased at the beginning of the intervention phase and showed an initial upward trend and then remained more constant afterwards. The data show comments and requests combined as long as they were initiations and not responses during the intervention.

David

David was the next participant to receive the intervention. The data displayed in

Figure 1 show that David’s use of thank you with his AAC was not counted when it was used non-contingently. The dependent measure for David was that “Thank You” would only count if it were used after he had received his food during lunch. No other AAC utterances, initiations, or responses are displayed within the data collected during David’s intervention. At baseline, David did not use the “Thank You” on his board but during the intervention phase he did use the board to indicate “Thank You;” however, the data should be interpreted with caution because there are several variables that need to be taken into consideration. Issues such as the relationship with the researcher; limited access to the AAC device prior to the study commencing; change of classroom setting; illness and this student’s history are all factors that may have impacted findings and these

67 are explored more fully in the Discussion chapter that follows. There was no immediate reward contingent on pressing “Thank You.” David was required to indicate that he wanted more by using the “More Please” key on his AAC board when he wanted food.

At baseline there were no initiations recorded for David. Prior to intervention the data were very low or at zero during baseline (see also, Soenksen & Alper, 2006;

Sansosti & Powell-Smith, 2008; Barry & Burlew, 2004). Following the introduction of the social narrative, the mean increase in initiations was .91 during the intervention phase. The highest actual number of correct “Thank You” initiations during a single session was 10. David’s intervention continued for fourteen days but, although there was an overall improvement in the mean number of initiations, the data were inconsistent. For example, after data points 10 and 11 remain at baseline there is the sharpest increase in trend and when data appeared to stabilize between data points 13 and 16 a downward trend followed.

Charles

Charles was the third and final participant to receive the intervention. Charles did not initiate communication with any peers during the baseline phase and so Charles’ baseline also stayed constant at zero. During the intervention phase the mean average for

Charles’ initiations was .096. Notably, at the second data point during the intervention

Charles did not initiate interaction at all whereas the rate was much higher at the fourth data point. During Charles’ intervention he would reiterate parts of his narrative, which indicated that he was mindful of the contents for at least some parts of his playtime.

Charles did not tap peers on the shoulder and the observer could not demonstrate or

68 model the behavior during this phase without introducing a confounding variable. One of

Charles’ questions after the reading of the narrative was whether he could demonstrate a tap on the shoulder and he was able to do this using his own shoulder and the researcher’s shoulder.

The Nonoverlap of All Pairs

The NAP index score was used to evaluate the level of change across the baseline and intervention phases. The larger the effect size, the larger the impact that the intervention had on the social initiation skill. Parker and Vannest (2009) suggested the following ranges: weak effects 0-31% (0-.31); medium effects 32%- 84% (.32-.84); large or strong effects 85%-100% (.85-1.0). The effect sizes of the NAP for social initiations were 90% (.9) for Caleb, 70% (.7) for David, and 90% (.9) for Charles. All index scores indicate a positive improvement from baseline to intervention phase and a strong effect, based on NAP ranges suggested by Parker and Vannest (2009). In addition p-values also support the significance of the results: Caleb 0.237; David .0059 and Charles .0051.

One unanticipated issue, that was difficult to control for and also problematic in terms of analysis, was the question of previous level of all students’ exposure to social skills teaching. There were no data to establish what social skills interventions had been attempted prior to this study or what social successes students had experienced. Both

Caleb’s and Charles’ mothers reported that they encouraged their sons to engage with friends. Caleb’s mother felt that Caleb was indifferent to whether or not he interacted with others. Charles’ mother reported that Charles appeared interested in playing with others but did not have the necessary skills to be able to initiate interaction.

Maintenance and Generalization

Maintenance

The third phase of Figure 1 shows maintenance skill data. At least three maintenance probes were taken for each participant. Caleb and David were visited two weeks after the intervention phase to establish whether initiation skills were maintained.

The number of initiations dropped for Caleb but still remained above baseline. Caleb’s mean rate of initiation at the maintenance phase was .17.

David’s rate was not measurable because he did not have access to his AAC board on any of the days that he was observed. During the maintenance period, David appeared to have made significant gains in social behavior. He was eating at the table with peers and not exhibiting any of the behaviors that were observed prior to the study commencing.

Charles’ maintenance probes were taken very soon after the intervention because his intervention was last to be introduced and, since the weather was colder, outdoor recess was coming to an end. Charles’ rate during the maintenance phase increased slightly and this increase may be explained by the fact that the maintenance data were taken so close to the end of the intervention.

The question of whether performance of skills is associated with the observer is discussed in the generalization section below. Unfortunately, data were not taken when the observer was absent because personnel on site had not been able to do so.

Longer term follow up, at six months, with Caleb’s special education teacher confirmed that he continued to comment and make utterances and reportedly said “Will

70 you play with me?” during outdoor recess but that often students did not respond so he would continue to play alone. The educational support paraprofessional (ESP) who accompanied Charles at recess reported that, on occasions when students went outside for recess, Charles continued to opt for the swing, as he had done prior to the intervention, if the play structure was open and that when the play structure was unavailable Charles would stand alone watching others or stand at the ESP’s side.

Longer term follow up with David revealed that he began to communicate verbally about six months after the study was conducted. He went to his music class and was asked to choose a flute. David responded “pink” and was given the pink flute. Prior to this study the researcher had observed David during the school summer program and noted that on a single occasion he cried “mom” and went to his backpack yet records indicated that he had never spoken.

Generalization

Students were observed for generalization at the end of their intervention phases when it was evident that they had made gains in initiation skills sufficient that generalization was a possibility. Generalization skills for the three participants are described anecdotally below.

Caleb. Caleb was observed playing indoors in his regular education classrooms immediately before recess. Caleb was observed in settings where he had an opportunity to generalize skills to play situations with typical peers. Caleb greeted the observer spontaneously and sat at a desk coloring alone. He frequently commented but the

71 utterances were undirected. When the observer moved to the other side of the classroom

Caleb continued to comment regardless of the absence of a listener.

David. David was observed in his special education classroom where he had eaten lunch but in the play area with construction toys. David noticed the observer enter the classroom and began to laugh. He watched the observer and crawled across the carpet laughing and watching the observer continually. David did not have his AAC board at this time and it was not visible in the classroom. David’s responses were not counted as initiations because they did not meet the specified criteria but he was fully engaged with the observer throughout this observation. David’s teacher reported that he had become much more engaged and that after the intervention phase he had been working with a different ESP with whom he appeared to be very happy.

Charles. Charles was also observed during an unstructured play activity in his regular education setting. When the observer arrived Charles uttered the observer’s name. Charles was observed playing in close proximity with peers; however, he did not initiate communication and the play is best described as solitary since he did not demonstrate any interest in the play activities of others around him. Both Charles and

Caleb were observed for 20 minutes.

Social Validity

Social validity checklists (IRP-15, Witt & Martens, 1984) were completed by one out of three parents and the special education teacher after the intervention. The checklists were not issued prior to the intervention because, at that time, the teacher was not aware of exactly what the study would entail. Parents were asked to omit questions

72 that relate only to teachers. Caleb’s mother sent a thank you card made by Caleb instead.

The special education teacher rated 10 questions as “strongly agree;” three as “agree” and two as “slightly agree.” David’s mother rated eight questions as “strongly agree,” two as

“agree,” and one as “slightly agree” (items 2, 6, 7, and 10 were unanswered). The study was socially validated through positive feedback from the special education teacher, two

ESPs, and the parents. Caleb’s parents stated that Caleb appeared to be engaged with siblings much more. However, Caleb’s siblings were aware that social skills were the focus of the intervention so it is difficult to tease out how much improvement was attributable to Caleb. David was described by his teacher as being “like night and day” because his demeanor changed so much. However, it is also difficult to attribute the change to a narrative when so many other changes took place simultaneously. Staff did not note any changes in Charles’ behavior.

Procedural Integrity

The story was read to the students at approximately the same time each day. The times varied slightly depending on the time classroom instruction was completed; how long Caleb and Charles took to eat lunch; whether there were announcements at lunchtime; whether students received medication and other delays pertaining to daily school functioning. A procedural integrity checklist was used for each session (Appendix

D) to confirm that the stated protocol was followed during the study. The procedural integrity checklist recorded that protocol was followed for 94% of opportunities.

Conclusion

In conclusion, the data indicate that all three participants made gains in their initiation skills but there was little evidence of maintenance and no evidence to support that skills were generalized. None of the students generalized the targeted initiation skills to a different situation. Charles did not use the tap on the shoulder with any student during observations and it is likely that he did not generalize the skill past the researcher and himself when he demonstrated what the tap on shoulder meant during the question sessions. Behavioral changes that David exhibited seemed to be more prevalent during maintenance observations but since he no longer appeared to have access to his AAC there was no opportunity to measure whether he continued to use the “Thank You” button appropriately. The gains in social skills acquisition for David were socially validated during conversations with the Special Education teacher.

One notable flaw in the study was that a period of fading was not included as part of the study. A fading period would have been useful for evaluating whether the students were likely to maintain skills and would have helped support students while the intervention was being withdrawn.

In conclusion, results appear to indicate that the narrative intervention was successful in raising initiation skill levels in all three students. Since autism is characterized by social skills deficits, it is encouraging that three students made gains in social skills during the period of this study. The multiple-baseline across participants design indicates that the gains were made at the time of the intervention. Several key issues may affect how the results are interpreted and these should be considered in

74 determining the efficacy of the narratives. For example, additional factors such as relationship with researcher; being accompanied by a listener; no information concerning previous exposure to social skills interventions and other issues are discussed more fully in the following chapter.

CHAPTER IV

DISCUSSION

The overarching purpose of this study was to add to the current research on narrative interventions for students with Autism Spectrum Disorder. While there is a growing body of literature that supports the efficacy of Social Stories™ as an intervention for students with autism, there is a lack of evidence that a narrative intervention has to adhere to a strict formula in order to yield positive findings. This study explored whether narratives that veered away from Social Story™ guidelines had potential for increasing social skills in students with autism. The following sections discuss the intervention and findings. A further section highlights strengths and limitations and the chapter concludes with recommendations for future research and practice.

The Social Narrative Intervention

The Study

The study fulfilled the principle objective of exploring whether a different type of narrative that did not adhere to Gray’s guidelines (2004) could be utilized for teaching social skills to students with autism and whether there would be positive outcomes. The aim of the study was not to attempt to compare and contrast the merits of Social Story™ with a different type of social narrative, instead, this study only sought to widen the scope of narrative interventions by exploring whether non Social Story narratives also yielded positive outcomes.

The findings of the study were encouraging insofar as all participants demonstrated gains in initiation skills during the intervention period. The study therefore

75 76 endorses the use of shorter, and less detailed, narratives as learning tools for students with autism and potentially provides for use with a wider range of student ability than had been previously thought.

Strengths of the Study

The greatest strength of this study was that, although Social Stories™ had been generally associated with positive outcomes, no prior investigation had used a social narrative that intentionally deviated from Gray’s guidelines to evaluate their relevance.

Several studies examined in the review of literature unintentionally deviated from the guidelines but this was the first study that purposefully employed measures to control for the deviation. Visuals were not included in the narrative and no other forms of prompt and reinforcement were offered. Sansosti’s Social Story Validity Checklist (Appendix C;

2005) was used when developing the narrative to ensure that it did not conform to Gray’s recommendations (2004). Subsequently, if the social narrative yielded positive outcomes then the study could lend itself to further exploration and make way for future studies to evaluate which elements of narrative interventions are important.

A further strength of this study is that it widened the scope of the review of literature and provided a comprehensive overview of every previous study in an attempt to explore fidelity to Gray’s guidelines (2004). Many previous studies had narrowed the review of literature to focus on studies relevant to the specific behaviors under review.

Differences in students’ ages, abilities, and behaviors also offered strength to this study. The three student participants in the study ranged in age from 5 years and 10 months to 9 years and 1 month old and exhibited very different abilities and skills. The

77 original recommendation was that only students who were capable of verbal communication and mentally trainable (Gray & Garand, 1993) would benefit from this type of intervention. One of the students in the study was reported to be non-verbal and used an Augmentative Assistive Communication (AAC) device. That student, David, appeared to make gains, although some were unanticipated and therefore described anecdotally. These gains were socially validated by the students’ mother, the special education teacher, and also the educational support paraprofessional (ESP) who all remarked on an increase in sociability.

The study also attempted to control for some confounds and threats to validity that presented in previous studies. The multiple-baseline across participants design offered design strength in demonstrating that the intervention produced the same results across all three participants. Specific details of the study were not shared with personnel involved with the students on site. The classroom teacher and the principal were only made aware of the wider purpose of the study, which was to help students develop and practice social skills. Time was also set aside so that the students had a change to become accustomed to the researcher in an effort to address any problems that might have been attributed to reactivity to being observed.

The study also probed for maintenance and generalization and findings show that there was some maintenance of skills but generalization was less evident and much more difficult to determine as discussed in the previous chapter. A further strength of the study was that the aim was to teach a new skill, as opposed to attempting to reduce or extinguish problem behaviors. Several other studies have attempted to increase behaviors

78 that were already present (Barry & Burlew, 2004; Sansosti & Powell-Smith, 2008;

Soenksen & Alper, 2006) but this study targeted acquisition of a new skill for three participants.

Limitations

This section highlights several issues that presented during the study and were either unanticipated or difficult to control for or measure. Some of the key issues were difficulty accessing student information and data, impact of researcher relationship with participants, and problems of recording social skill gains that presented outside scheduled recording time.

One of the inherent difficulties of any study of students with autism is that autism is a spectrum disorder that presents very differently across students. As discussed previously, in Chapter 1, numbers of students diagnosed with autism continue to increase.

While student differences bring strength to the study they also raise some questions.

David reportedly did not speak and did not appear to access an AAC on a regular basis.

Prior to the intervention the AAC was not evident therefore a teaching phase needed to be incorporated so that David could become accustomed to using the AAC device. However, this introduced several variables wherein David spent more 1:1 time with the researcher and his eating arrangements (environment, personnel and AAC) changed immediately prior to the intervention phase. Increases in initiation skills could be attributed to any of these changes. During the maintenance inspections the researcher provided David with his AAC but he did not appear to be using it otherwise. David demonstrated some rote behaviors consistent with criteria for autism but his behaviors may have been attributable

79 to a different diagnosis. Little was known about David’s background but reportedly there was a record of abuse. Unfortunately, records were not available to the researcher.

Unavailability of records and data, especially evaluation documents, and information pertaining to interventions that had been implemented in the past presented some problems when attempting to determine a causal relationship. David appeared to respond differently to different personnel. Relationship may have been a factor that impacted results. The relationship variable was not controlled for and complicated by the fact that the researcher replaced the Educational Support Paraprofessional (ESP) who was responsible for feeding David at lunchtime. Furthermore the positive behavior may have been generalized to David’s relationship with his next ESP.

To control for relationship in future studies, the study should include several different individuals who work regularly with participants to assess for variability. Data were not taken when the observer was absent because personnel on site could not do so.

Relationship also appeared significant for Caleb. Caleb would shout and greet the researcher every time they met and initiated the greeting with no prompt prior to the narrative reading. This was not measured in the study as the greetings occurred before the narrative reading and data collection point.

Differences, such as the addition of a novel ‘listener,’ who accompanied participants, may have been a relevant factor. Observer reactivity was controlled for but more time should have been devoted to this phase. Observer reactivity also becomes questionable when inspecting the maintenance data for Charles in particular. Charles’ initiations which were zero at baseline continued after the intervention phase and this

80 may be attributable to observer presence or reactivity. The question is whether the narrative is associated with the increase in initiations or whether any encouragement or strategy would have borne similar results. This is especially difficult to answer when there are no comparable data on previous interventions for these participants.

Furthermore, some of the implementation strategies may be as important as the narrative.

Two key points were noted in Chapter 1, first, a Social Story™ is intended to be read and reiterated and can also be easily inserted into routines and so it appeals to the rote learning style attributed to students with autism. Second, “repetitiveness can also work to the individual’s benefit by using the drive for routine as a prosocial strategy to organize activity in a functional, albeit highly structured and repetitive manner” (Siegel,

2003, p. 235). The narrative intervention was conducted at the same time each day, the same narrative was read by the same researcher each day, and the same questions were asked. Students had 1:1 attention during the readings. Repetition, routine, rote, and predictable programming may have had the biggest bearing on the improvement in social skills but these elements are difficult to deconstruct and isolate.

The significance of some other factors was also difficult to determine. Caleb and

Charles also played in closer proximity with peers that had been observed prior to the intervention but the significance is difficult to determine especially when proximity could be incidental, accidental, unintentional or short lived. The significance of proximity is also difficult to evaluate in terms of quality of interaction or whether it is indicative of emergence of skill. For example, when both students were observed in the unstructured classroom setting they were close to others but appeared indifferent and engaged in

81 solitary play. Conversely, proximity and personal space often pose difficulty for students with autism.

Data for maintenance and generalization were disappointing. A fading phase should have been incorporated to withdraw the narrative intervention condition gradually so that students’ needs could be evaluated throughout the process. A fading stage would also have offered insights into how to program for maintenance. Findings in this study do not support generalization of skills across situations using a single narrative intervention and future studies should address this issue because inability to generalize is crucial for individuals with autism.

The narratives for Caleb and Charles were not setting specific but both stories started with “At recess…” Typically however, recess occurred in one setting. The skills

(i.e., dependent measures) were only exhibited in the setting that participants went to immediately after being exposed to the narrative. Caleb’s utterances were not directed during the generalization observations so were not counted as generalization. The question of “whether the ‘directed’ utterances were intended for a listener or not,” was considered and those that met criteria were coded because the question was unanswerable by anyone except Caleb.

Significance of Findings

Regardless of what specific elements were attributable to the increase in social skills, the findings confirm that there was an increase in social skill acquisition across all three participants. This study appears to confirm that a short narrative that is clear and specific is efficacious in teaching social initiation skills to students with autism who

82 exhibit different levels of functioning. This finding is very helpful when designing interventions for students whose comprehension is questionable especially when compared with more language embedded stories recommended by Gray (2004). For example, Scattone, Tingstrom, and Wilczynski (2006) used a narrative that consisted of three paragraphs and a plethora of options. Students who struggle with processing and sequencing and general comprehension skills can utilize a shorter, simpler narrative.

Narratives appear to have a wider application than previously thought. Moreover, there should be no assumption that any student is not ‘mentally trainable’ (Gray & Garand,

1993) or that because a student does not communicate verbally that the student cannot benefit from a social narrative or effectively communicate in response to a social narrative.

These narratives issued a single clear directive and this may support the importance of directive statements in Gray’s Social Stories™ especially since students with autism tend to need very concrete and rote directions. This was evidenced by several reiterations of parts of the narrative by Caleb and Charles. Further research should be conducted to examine which aspects of a narrative lend themselves to positive outcomes especially factors such as repetition and rote and the manner in which narratives are delivered.

Peer training would also extend the scope of teaching so that when students initiate an interaction peers will respond appropriately so that the interactions can extend beyond initiation and utterance to back and forth exchanges. Teaching for generalization is paramount. More studies need to address how to teach for generalization as the taught

83 skills simply do not transfer for students with autism in the same way as they would for typical peers.

Implications

The review of literature demonstrated that studies that deviated from Gray’s guidelines (2004) were associated with positive outcomes thus diminishing the distinction between Social Story™ and any other type of narrative. This study further demonstrates that following rigorous guidelines is unnecessary and confirms the findings of the review of literature. Moreover, if the structure of story is irrelevant then this paves the way for exploration of other constants such as visual presentation, auditory reading, reader attention, repetition, and rote.

Social Change

As increasing numbers of students with autism continue to be identified, there is a continuing need for development and research into interventions that teach social skills.

Social skills programming needs to be a part of the curriculum for all students and programming should extend to unstructured social time. Peer training is essential as is heightening awareness of how autism presents and what defines the disability. Teacher training needs must be identified and supported. Teachers should be encouraged to participate in research and provided with opportunities to learn about social skill interventions as well as how to incorporate and integrate implementation strategies.

APPENDICES

APPENDIX A

DIAGNOSTIC FEATURES OF AUTISM

Appendix A

Diagnostic Features of Autism

Restricted, repetitive, and Markedly abnormal or impaired stereotyped patterns of behavior, development in social interaction interests and activities Stereotyped body movements

Gross and sustained impairment An encompassing preoccupation Hand flapping, finger flicking, in reciprocal social interaction with one or more stereotyped whole body rocking, dipping, or behavior swaying Impairment in use of multiple nonverbal behaviors (eye to eye Restricted pattern of interest that is Abnormalities of posture, walking gaze, facial expression, body abnormal either in intensity or on tiptoe, odd hand movements, postures and gestures) and focus and body postures. communication Inflexible adherence to specific Fascination with movement, Failure to develop peer nonfunctional routines or rituals spinning or revolving objects, relationships opening and closing doors Stereotyped and repetitive motor Lack of understanding of the mannerisms or persistent Attachment to inanimate object conventions of social interaction preoccupation with parts or (e.g., string or rubber band) objects Lack of spontaneous seeking to share enjoyment, interests, or Preoccupation with one narrow achievements with other people interest

Lack of social or emotional Resistance to change reciprocity

Lack of awareness of others

Disturbance in the pragmatic (social use) of language, e.g., failure to understand humor or nonliteral aspects of speech

APPENDIX B

“ANALYSIS OF SOCIAL STORY™ INTERVENTIONS

FOR STUDENTS WITH AUTISM”

Appendix B

“Analysis of Social Story™ Interventions for Students With Autism”

Age/ Gend Adhered to Ability Measures/ Maintena Duratio Asperg ASD High Other Questions Soci Interobse # of er Guidelines: Efficaci Treatme Author/Title MAS/ Background Research Purpose of Read By/ When/ nce/ n of Auti er's (general Functio Disabilit Illustratio Comprehe al rver Particip Male IV Fully (F) Setting ous: nt /date FBA Diagnostic Design Intervention Frequency Generaliz Interven sm Syndro classifica ning ies/ ns nsion Valid Agreeme ants (M) Partly (P) Y/N Fidelity Information ation tion me tion) Autism Abilities Check ity nt Femal Not(N) e (F) Swaggart & 3 11F, Informal Informal checks on AB Appropriate SS + Teacher or 28 days X PDD- P.Deliberatel Photograp Univers Y N N N Gagnon. 7M,7 environm pre-literacy and (deliberate greeting/ Social para/1x per mod- NOS y expanded hs ity Using Social M ental understanding decision not aggression/ Skill morning seve guidelines. medical Stories to assessm to return to sharing Interventio re Ratio Center. Teach ent baseline). n Model incorrect Self Social and (Simpson Contain Behavioral & Regan, ed Skills to 1998) laborat Children Response ory with Autism. cost Class 1995 reinforcem ent schedule. Kuttler, 1 12M Brigance, 78; ABAB Reduce 2 SS classroom No 19days X Fragile P. Structure Y Shari, Myles Callier-Azusa Scale precursors to (other staff/prior to work X, of one book & Smith. (Stillman,78) tantrum reinforcers and Intermitt adheres to The Use of behavior included) lunchtime/daily ent guidelines Social Explosiv but story Stories to e targets Reduce Disorder decrease in Precursors behavior not to Tantrum addition of Behavior in skills. a Student with Autism. 1998 Hagiwara, 3 7y11 MAS ABC;BASC; PEP-R Multiple Hand Multimedi Introduced by Some, 24 X P. 1 out of 3 Multimedia no across Y Y Myles & mM, up to 5 consecutive Baseline washing/on a social teacher, para or across SS environ (somew Smith. A 9y11 sessions Across task behavior story researcher but settings, me-nts hat) Multimedia mM, Settings trained in how to but no Social Story 7y3m use computer. long term Intervention: M. Once daily measures Teaching Skills to Children with Autism.1999

88 89

Age/ Gend Adhered to Ability Measures/ Maintena Duratio Asperg ASD High Other Questions Soci Interobse # of er Guidelines: Efficaci Treatme Author/Title MAS/ Background Research Purpose of Read By/ When/ nce/ n of Auti er's (general Functio Disabilit Illustratio Comprehe al rver Particip Male IV Fully (F) Setting ous: nt /date FBA Diagnostic Design Intervention Frequency Generaliz Interven sm Syndro classifica ning ies/ ns nsion Valid Agreeme ants (M) Partly (P) Y/N Fidelity Information ation tion me tion) Autism Abilities Check ity nt Femal Not(N) e (F) Norris & 1 8F Iowa Test of Basic AB Inappropriate 3 x Social Daily/ before No X Not known Symbols No Y Y Dattilo. Skills social Stories situation/ by Evaluating interactions Jennifer in Effects of A secluded area Social Story Intervention on A Young Girl with Autism. 1999 Brownell. 4 case 6-9M 5 days data Counterbal Tv talk, loud Musical, Author/ NO 20 days X Y. 1997 Classro Y Y Musically studies collection anced vocalizations, non- secluded om Adapted x1 child ABAC/ABA following musical area/daily Social C directions SS and Stories to additional Modify reinforcers Behaviors in . Students with Autism: Four case Studies. 2002 Lorimer, 1 5M MAS Informal checks on ABAB Tantrums, SS Therapists/parent Not 24 X Y PCS Attempts to home Y Y Y Simpson, pre-literacy and interrupting, (Existing s/at home/daily/as assessed assess Smith understanding screaming, Sp & lang, needed understandi Myles, & hitting OT & ng Ganz: The Behavior Use of Therapy Social services Stories as A held Preventive constant) Behavioral Intervention in A Home Setting with A Child With Autism. 2002 Scattone, 3 15M K: Stanford Binet Multiple Classroom SS & Read by students No data 22 X Y. 1998 Y Classro Y Y Y Y Wilczynski, (J) Intelligence Scale Baseline Disruption J: prompts J (before target sessions om Edwards & 7M 4,PPVT-3 Across Inappropriate situation) & K Rabian. (K), Expressive Participants staring; K: (before class). Decreasing 7M Vocabulary. J: K- falling off Read by teacher Disruptive (H) ABC. H: K-ABC chair; H: to H. Behaviors in shouting Children with Autism Using Social Stories. 2002

Age/ Gend Adhered to Ability Measures/ Maintena Duratio Asperg ASD High Other Questions Soci Interobse # of er Guidelines: Efficaci Treatme Author/Title MAS/ Background Research Purpose of Read By/ When/ nce/ n of Auti er's (general Functio Disabilit Illustratio Comprehe al rver Particip Male IV Fully (F) Setting ous: nt /date FBA Diagnostic Design Intervention Frequency Generaliz Interven sm Syndro classifica ning ies/ ns nsion Valid Agreeme ants (M) Partly (P) Y/N Fidelity Information ation tion me tion) Autism Abilities Check ity nt Femal Not(N) e (F) Kuoch & 3 3y10 PCS for recognition ABA 2, aggression, SS/correct parent at home/ Y 17/29/39 X 2X PDD- Y. 2000 Cartoons N home/ Y Y Y Mirenda. mM, of facial ACABA1 crying, yelling/ ive students at home/ days NOS (1) (assessmen summe Social Story 5y9m expressions. screaming, feedback intervention t on visual r school Intervention M, Interest in books throwing up, specialists at understandi s for Young 6y4m hands inside summer school ng) Children M pants/cheatin with Autism g at games, Spectrum negative Disorders. comments 2003 about losing Agosta, 1 6M Investigat Teacher ABCA Promote 1 SS + or Teacher 2x daily 35 X Y. Gray and Picture Self- Y Y 1 Graetz, ed the collaboration. socially - prior to transition sessions Garand 1993 Communic contain observer Mastropieri function Counted screaming acceptable reinforcem to circle + 1x or ation ed taking & Scruggs: of behaviors behaviors and ent more at circle System classro data Teacher- behaviors reduce system (Mayer- om in Researcher screaming, Johnson, public Partnerships yelling, crying 1981-2003 school to Improve and loud Social humming. Behavior Through Social Stories. 2004 Barry & 2 5F, ABCD SS (also Teacher/daily/clas No data 21 days X Not known Yes. No Classro Y N Y Burlew. 8M Multiple corrective sroom Seve Photograp om Using Social baseline feedback, re hs Stories to across hierarchy Teach participants of Choice and prompts) Play Skills to Children with Autism. 2004 Crozier & 1 8M MAS Analytical Reading ABAC Reduce SS with Student/ Y 25 X N. 3:5ratio Y Y Classro Y Y Y Y Tincani. Inventory/word lists reversal talking out prompts/ classroom next om Using and comprehension SS no door/daily Modified prompts Social Stories to Decrease Disruptive Behavior of a Child with Autism. 2005

Age/ Gend Adhered to Ability Measures/ Maintena Duratio Asperg ASD High Other Questions Soci Interobse # of er Guidelines: Efficaci Treatme Author/Title MAS/ Background Research Purpose of Read By/ When/ nce/ n of Auti er's (general Functio Disabilit Illustratio Comprehe al rver Particip Male IV Fully (F) Setting ous: nt /date FBA Diagnostic Design Intervention Frequency Generaliz Interven sm Syndro classifica ning ies/ ns nsion Valid Agreeme ants (M) Partly (P) Y/N Fidelity Information ation tion me tion) Autism Abilities Check ity nt Femal Not(N) e (F) Delano & 3 6M,6 Informal Multiple Probe Multiple Increase SS, peer Experimenter/imm Probes 37-45 X Y.2000 Picture Comprehen Play Y Y Y Y Snell. The M, assessm Across Participants/ Probe duration of mediation ediately prior to show sessions Symbol sion area of Effects of 9M ent on peer comparison Across social session generalizat format (1 Assessmen resourc Social preferred data Participants engagement/ ion in 2/3 text only) t e Stories on play assess classro the Social activities frequency om at Engagemen element t of Children ary with Autism. school 2006 Hutchins & 2 6M, Diary entry AB Investigate SS/CSC 3x pw for 6 weeks X X P. 1995, Color CSC Collaboratio At Y:M, N:F Y X Prelock. 12F baselines for social whether revised 1998. Ratio n home Using Social validity. Audio taped outcomes are during not followed Stories and family interview. socially valid. process Comic Strip PPVT-3rd Ed. Conversatio Autism Diagnostic ns to Observation Promote Schedule Socially Valid Outcomes for Children with Autism. 2006 Reynhout & 1 8y9m Adaptive Behavior ABC Decrease SS (+ Researcher or 44 X X X Y. 2003 Photograp Yes Small Y: Y Carter. M Inventory (brown repetitive reinforcers teacher/ daily/ sessions Seve hs room cannot Social Story and Leigh, 1986); tapping , stickers classroom/ prior re adjoinin be Efficacy with CARS ) Schopler, behavior and praise to lessons when g attribute A Child with Reichler & Renner, during held data were classro d to SS ASD and 1986); Renfrew reading constant) collected om Moderate Language Scales Intellectual Action Picture Test Disability. (Renfrew, 1997) 2007 PPVT-III (Dunn & Dunn, 1997) Ozdemir: 3 5y6m Informal Social Skills Rating Multiple Effectiveness Multimedi Researcher/ Generaliza 45 X Y .1993 HyperCard Yes School Y Y Using M, Interest System (Gresham, Baseline of multimedia a SS; beginning of each tion: 2 ; sessions with playroo Multimedia 6y2m Inventory Elliot, 1990); Across SS on Peer play session/3x Maintenan movies of m Social M, for Peabody Individual Participants duration of involveme per week ce:3 social Stories to 6y4m. motivatio Achievement Test, appropriate nt skills Increase M n Revised (Markwardt, social Appropriate 1989); Children’s engagement Social Autism Rating Scale with peer Engagemen (Schopler et al, typical t in Young 1980). Children with Autism. 2008

Age/ Gend Adhered to Ability Measures/ Maintena Duratio Asperg ASD High Other Questions Soci Interobse # of er Guidelines: Efficaci Treatme Author/Title MAS/ Background Research Purpose of Read By/ When/ nce/ n of Auti er's (general Functio Disabilit Illustratio Comprehe al rver Particip Male IV Fully (F) Setting ous: nt /date FBA Diagnostic Design Intervention Frequency Generaliz Interven sm Syndro classifica ning ies/ ns nsion Valid Agreeme ants (M) Partly (P) Y/N Fidelity Information ation tion me tion) Autism Abilities Check ity nt Femal Not(N) e (F) Sansosti & 3 6y6m GARS,GADS,OWLS Multiple Improve Computer Played by Y 29 X X Y.1998, Video Video show Recess Y Y Y Y Powell- M, ,WPPSI-III, RIAS Baseline social presented, teacher, para or sessions 1993, 2002 me how outdoor Smith: 8y10 Across communicatio video behavior areas Using mM, Participants n rate in modeled specialist/in Computer 10y6 general (using classroom/ 1x per Presented mM education peer) SS, day before target Social environment prompts situation Stories and Video Models to Increase the Social Communicat ion Skills of Children with High Functioning Autism Spectrum Disorder. 2008 Scattone. 1 9M Kauffman Brief Multiple Improve eye 3xSS + Viewed with 1st Generaliza 15 X Y. 2000 video medical Y 2/3 Y Y Y Enhancing Intelligence Test; Baseline contact, video author, video tion weeks; center skills the Wechsler Individual Across smiling and modeling pages narrated by 24 Conversatio Achievement Test; behaviors initiations adult/in clinic also sessions nal Skills of data for target viewed at home a Boy with behaviors collected. with mother Asperger's Disorder Through Social Stories and Video Modeling. 2008 Adama, 1 7M FA (O' Videotaped target ABAB Target crying, SS (also Parents/prior to Yes: 48 X P. Gray & home Y Y Y Gouvousis, Neill et al behaviors falling and verbal homework time Maintenan sessions Garand, VanLue & 1990) hitting & redirection ce 1993 Waldron. screaming from (targeted 4 Social Story parents) behaviors Intervention: simultaneou Improving sly/not Communicat recommende ion Skills in d) A Child With ASD. 2004

Age/ Gend Adhered to Ability Measures/ Maintena Duratio Asperg ASD High Other Questions Soci Interobse # of er Guidelines: Efficaci Treatme Author/Title MAS/ Background Research Purpose of Read By/ When/ nce/ n of Auti er's (general Functio Disabilit Illustratio Comprehe al rver Particip Male IV Fully (F) Setting ous: nt /date FBA Diagnostic Design Intervention Frequency Generaliz Interven sm Syndro classifica ning ies/ ns nsion Valid Agreeme ants (M) Partly (P) Y/N Fidelity Information ation tion me tion) Autism Abilities Check ity nt Femal Not(N) e (F) Scattone, 3 8M,8 Kaufman Multiple Increase SS Initially read to 33 X Y. 1998 No Comprehen Unstruc Y 1; N 1; Y Y Y Tingstrom & M, Assessment battery Baseline Appropriate (unanticip students by sessions sion check tur-ed somewh (needs Wilczynski. 13M for Children. Across Social ated teacher, then read free at 1 improve Increasing Diagnostic Participants Interactions teacher by participants/ time at ment Appropriate Achievement for Children prompts) classroom/ 5 school Social Battery-2nd Ed, minutes before Interactions Universal Non- session of Children Verbal Intelligence with Autism Test., Kauffman Spectrum Test of Educational Disorders Achievement, Using Social Wechsler Individual Stories. assessment Test 2006 Crozier & 3 3-5M VABS,GARS, ABAB (x2), Increase SS (with Researcher daily/ Yes 24-27 X Y.2000 Yes Urban Y Y Y Y Tincani. Differentiated Ability ABACBC appropriate prompts classroom/ prior sessions Univers Effects of Scale. Mullen Scale (x1) play, for to target activity ity Pre- Social of Early Learning. decrease communic school Stories on VABS wandering, ation Prosocial increase ABACBC Behavior of verbal design) Preschool communicatio Children n with Autism Spectrum Disorders. 2007 Goldstein, 5 6y6m CARS;PPVT- Multiple Social skills: SS, Peer Peer/2x Limited 15-19 X P. 1993 Y Y (4/5 media Y Thiemann. M- R,TOLD-2,TONI- Baseline secure mediation week/media room data sessions (Multi- simple room Effects of 12y2 2,SSRS, Woodcock Across attention; and token / 30-38 strategy interrogativ Visually- mM Reading-Mastery language initiate reinforcers weeks intervention e to check Mediated Tests Revised skills comments; included understandi Intervention initiate reinforcers ng) on the requests; and peers). Social contingent Communicat responses ion of Children with pervasive Developmen tal Disorder. 1999

Dodd, Hupp, 2 9y10 2nd grade reading Multiple Decrease Mother/up 12 PDD- Y. 2004 Yu-Gi-Oh Home Y Y Y Y Jewell & mM, level indicated by baseline excessive to 3x per sessions NOS Krohn: 12y7 mothers; Illinois across directions and week/hom over 4 Using m M Stanford participants increase e weeks parents and Achievement Test; (1) and compliments Siblings Wechsler Multiple During A Intelligence Scale baseline Social Story for Children, 3rd Ed; across Intervention Wechsler Individual behaviors for Children Achievement Test) (both) Diagnosed with PDD- NOS. 2008

APPENDIX C

THE SOCIAL STORY™ VALIDITY CHECKLIST

Appendix C

The Social Story™ Validity Checklist

Social Story Validity Checklist

Reviewer Name: ______Social Story Author: ______

Social Story Title:______

Directions: Please review the attached social story. Categoriz e each sentence into one of the following sentence types. Then complete the following sections.

I. Sentence Counts

1. How many sentences were there of each of the following categories?

Required Sentences Additional Sentences (not required) Descriptive Control Perspective Cooperative Directive Affirmative

2. How many total sentences were there in the social story? ______

II. Sentence Ratio

3. Does the story contain any Control or Cooperative sentences? _____ Yes _____ No

If you answered Yes to the above question, go on to complete #4. If you answered No, go on to #5.

4. If you answered Yes to #3, complete the following:

_____ Total number of Descriptive, Perspective, Affirmative and Cooperative statements

_____ Total number of Directive a nd Control statements

Does the story meet the Complete Social Story Ratio: 2-5 Descriptive, Perspective, Affirmative, and Cooperative sentences for every Directive or Control sentence? _____ Yes _____ No

5. If you answered No to #3, complete the following :

_____ Total number of Descriptive, Perspective, and Affirmative statements _____ Total number of Directive statements

Does the story meet the Basic Social Story Ratio (2-5 Descriptive, Perspective, Affirmative sentences for every Directive sentence)? _____ Yes _____ No

Sansosti (2005). © University of South Florida

100 101

III. Validity of Sentences

The following is a list of characteristics for each sentence type. Review each sentence type and determine if the sentences in this social story meet these criteria. Do ALL of the Descriptive sentences… …explain the who, what, when, where, and why of a social ___Yes ___No situation? If you answered no, please describe which sentences do not meet this criteria and why not.

Do ALL of the Perspective sentences… …describe the reactions and/or feelings of others? ___Yes ___No If you answered no, please describe which sentences do not meet this criteria and why not. Do ALL of the Directive sentences… … identify a desired social skill or behavioral response cue? ___Yes ___No … use phrasing that emphasizes effort (e.g., “I will try to…” or “I will work on…” (rather than phrasing that merely states behavior, such as “I will…”)? ___Yes ___No If you answered no, please describe which sentences do not meet this criteria and why not. Do ALL of the Affirming sentences… … either reference a rule/law, stress an important point, or reassure? ___Yes ___No … immediately follow a Descriptive, Perspective, or Directive ___Yes ___No sentence? If you answered no, please describe which sentences d o not meet this criteria and why not.

Do ALL of Cooperative sentences… … identify what others will do to assist the individual? ___Yes ___No If you answered no, please describe which sentences do not meet this criteria and why not.

Do ALL of the Control sentences… … reflect individual interests of participant to aid in recall of story? ___Yes ___No If you answered no, please describe which sentences do not meet this criteria and why not.

Sansosti (2005). © University of South Florida

APPENDIX D

CONSENT FORMS

Appendix D

Consent Forms

AUDIO/VIDEOTAPE/PHOTOGRAPH CONSENT FORM

I agree to the video taping of my son at ------Elementary School during the month of October, 2009

______Signature Date

I have been told that I have the right to see the video tape before it is used. (The video taping is strictly for data collection purposes and will not be viewed by anybody but the primary researcher and one other member of staff who will check for reliability). I have decided that I:

____want to see the tapes ____do not want to see the tapes.

Sign now below if you do not want to see the tapes. If you want to see the tapes, you will be asked to sign after seeing them.

Suzanne Gikas and other researchers approved by Kent State University may / may not use the tapes made of my child. The original tapes or copies may be used for:

_____this research project _____teacher education _____presentation at professional meetings

______Signature Date Address:

103 104

Consent Form: Social Narratives

Dear Mr. and Mrs. September 25th, 2009

I have been approached by a teacher, Mrs. Gikas, who would like to conduct research on social narratives. The reason for this is because social narratives may be very effective ways to communicate information to children with developmental delays. I would like you to let your child take part in this project. If you decide to do this, your child will be asked to listen to a story once per day and attempt to answer questions verbally (to the best of his ability), for a total duration of 15-20 minutes per day. A social narrative is a simple, brief story that draws upon a situation that is causing the student some difficulty or a situation where the student might benefit from having more information. The story focuses on modeling a desirable response to the situation. The story offers the student a different way of responding and is read to the student over a period of time so that they may think about a different response or have some alternative ways of dealing with the situation presented to them.

Participants and schools will not be named and thus remain confidential so that no details will indicate the identity of your son or the school beyond ‘a school in Ohio.’ In order that the story can be individually tailored to best match your son’s cognitive ability and strengths it will be necessary to provide Mrs Gikas with academic information about your son from his school records, specifically, records that demonstrate comprehension ability. Mrs Gikas is an Ohio State licensed teacher. All information disclosed will be absolutely confidential.

If you do give consent for your child to take part in this project s/he may benefit from individual instruction and also from having a book individually written to focus on his needs. I would like to advise you that taking part in this project is entirely up to you, and emphasize no one will hold it against your child if you decide not to do it. If your child does take part, he may stop at any time.

If you want to know more about this research project, please call Mrs Gikas at 330-722-8169; or Dr Lyle Barton at 330-672-2294. The project has been approved by Kent State University. If you have questions about Kent State University's rules for research, please call Dr. John West, Vice President of Research, Division of Research and Graduate Studies (Tel. 330.672.2704).

You will get a copy of this consent form.

Sincerely,

------

Teacher/Intervention Specialist

B. CONSENT STATEMENT(S) 1. I agree to let my child take part in this project. I know what he will have to do and that s/he can stop at any time.

______Signature Date

APPENDIX E

CLASSROOM INTERVENTION QUESTIONNAIRE

Appendix E

Classroom Intervention Questionnaire

The purpose of this questionnaire is to obtain information that will aid in the selection of classroom interventions. These interventions will be used by teachers of children with behavior problems.

Please circle the number that best describes your agreement or disagreement with each statement using the scale below.

1=strongly 2=disagree 3=slightly 4=slightly 5=agree 6=strongly disagree disagree agree agree

1. This would be an acceptable intervention for the child’s problem behavior. 1 2 3 4 5 6

2. Most teachers would find this intervention appropriate for behavior problems in addition to the one described. 1 2 3 4 5 6

3. This intervention should prove effective in changing the child’s behavior. 1 2 3 4 5 6

4. I would suggest the use of this intervention to other teachers. 1 2 3 4 5 6

5. The child’s problem behavior is severe enough to warrant use of this intervention. 1 2 3 4 5 6

6. Most teachers would find this intervention suitable for the behavior problem described. 1 2 3 4 5 6

7. I would be willing to use this intervention in my classroom/school. 1 2 3 4 5 6

8. This intervention would not result in negative side effects for the child. 1 2 3 4 5 6

9. This intervention would be appropriate for a variety of children. 1 2 3 4 5 6

10.This intervention is consistent with those I have used in my classroom. 1 2 3 4 5 6

11.The intervention was a fair way to handle the child’s problem behavior. 1 2 3 4 5 6

12.This intervention is reasonable for the behavior problem described. 1 2 3 4 5 6

13. I liked the procedures used in this intervention. 1 2 3 4 5 6

14.This intervention was a good way to handle this child’s behavior problem. 1 2 3 4 5 6

15.Overall, this intervention would be beneficial for the child. 1 2 3 4 5 6

106

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