Modifying Behaviors of Children with Autism: the Use of Musically Adapted Social Stories in Home-Based Environments Yuen-Man Chan

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THE FLORIDA STATE UNIVERSITY

COLLEGE OF MUSIC

MODIFYING BEHAVIORS OF CHILDREN WITH AUTISM: THE USE OF MUSICALLY ADAPTED SOCIAL STORIES IN HOME-BASED ENVIRONMENTS

YUEN-MAN CHAN

A Thesis submitted to the College of Music in partial fulfillment of the requirements for the degree of Master of Music

Degree Awarded: Fall Semester, 2005

The members of the Committee approve the thesis of Yuen-man Chan defended on October 31, 2005.

______Alice-Ann Darrow Professor Directing Thesis

______Clifford K. Madsen Committee Member

______Jayne M. Standley Committee Member

The Office of Graduate Studies has verified and approved the above named committee members.

This thesis is dedicated to children with special needs in Hong Kong.

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ACKNOWLEDGEMENTS

I am deeply appreciative of Dr. Alice-Ann Darrow for her guidance and assistance in producing this thesis. She has instilled confidence in me when things get frustrating. She has also made me aware of the potentials I possess. I wish to acknowledge the Board of Trustees of the Hong Kong Jockey Club Music and Dance Fund, who approved the award of scholarship for me to study the Master’s Program in Music Therapy at Florida State University. Without the grant, I would never be able to attain my dream of being a music therapist. I am indebted to the children who participated in this research. Their participation and the permission of their parents made this project possible. I am grateful to Mrs. Wong and Mrs. Yip, who had helped me with the participant recruiting process. It is my great pleasure to know all of them. Special thanks are offered to Zoe Ma, Wah-hei Ng, Cho-wai Joyce Lam, Janet Yau, and Wing-yin Cindy Chan, for their technical support and willingness to help. I wish to thank my friend, Bill Madden, who has helped me a great deal when I am almost 10,000 miles away from home. He is my family in Tallahassee! Thanks are extended to my best friend, Emily Ng, who has called regularly from Hong Kong to give me words of encouragement during these two and a half years. Thanks also for her listening ear. I must give tribute to my parents who brought me to my first piano lesson when I was six. Thank you for their love and bringing music to my life. Finally, special gratitude goes to my beloved, Yung-wai Desmond Chan, who has unconditionally given his love, support, and encouragement in the past five years. I am unable to express how grateful I am to him for his endless patience.

TABLE OF CONTENTS

List of Tables ...... vii List of Figures ...... viii Abstract ...... ix

1. INTRODUCTION ...... 1

Autism ...... 1 Social Deficits in Autism...... 2 Pertinent Techniques...... 4 Statement of Purpose ...... 5

2. REVIEW OF LITERATURE ...... 6

Research on Autism...... 6 Cause of Social Deficits ...... 7 Social Skills Techniques ...... 8 Music Therapy and Autism ...... 10 Musical Responses of Children with Autism Music Therapy with Children with Autism Social Stories...... 15 Developing a Social Story Intervention Effectiveness of Social Stories Rationale ...... 21

3. METHOD ...... 23

Participants ...... 23 Design ...... 23 Procedures ...... 23

4. CASE STUDIES...... 26

Case Study I ...... 26 Background Target Behavior Implementation Procedures Results Follow-up Case Study II ...... 29 Background Target Behavior Implementation Procedures Results Follow-up Case Study III...... 32 Background Target Behavior Implementation Procedures Results Follow-up Case Study IV...... 35 Background Target Behavior Implementation Procedures Results Follow-up

5. DISCUSSION ...... 38

APPENDICES ...... 41

A English Translations of the Original Chinese Social Stories...... 41 B Original Music for the Social Stories ...... 44 C Social Story Books...... 49 D Human Subjects Committee Approval Letter...... 69 E Parental Consent Form ...... 71 F Child Assent ...... 73

REFERENCES ...... 75

BIOGRAPHICAL SKETCH ...... 85

LIST OF TABLES

Table 1: Basic Social Story Sentences...... 16

Table 2: t-tests for Condition Comparisons for participant Mike...... 28

Table 3: t-tests for Condition Comparisons for participant Toby...... 31

Table 4: t-tests for Condition Comparisons for participant Cindy ...... 34

Table 5: t-tests for Condition Comparisons for participant Karen ...... 37

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LIST OF FIGURES

Figure 1: Duration of Proper Sitting exhibited by participant Mike by condition ...... 28

Figure 2: Frequency of Aberrant Vocalizations exhibited by participant Toby by condition ...... 31

Figure 3: Frequency of Aggressive Behaviors exhibited by participant Cindy by condition ...... 34

Figure 4: Duration of Putting Things in Mouth exhibited by participant Karen by condition ...... 37

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ABSTRACT

CHAPTER 1

INTRODUCTION

Autism is an incurable developmental disorder with an onset prior to the first thirty-six months of life. It affects two to five individuals in every 10,000 without any ethnic, racial, or socioeconomic boundaries (Davison, Neale, & Kring, 2004). In some countries, however, the prevalence of autism may be higher than this reported median rate. For example, the estimated number of people with autism in Hong Kong was 7,040 out of the seven-million total population in 2002 (Health, Welfare and Food Bureau, Hong Kong, 2005). In other words, autism occurs in ten individuals in every 10,000 in Hong Kong, a rate double the United States. It is unclear if the increased incidence is due to the differences in diagnosis or the more frequent incidence of the disorder in the territory. Efforts are needed to develop appropriate treatment programs for these individuals. The purpose of this research is to investigate the effectiveness of an increasingly popular strategy, social story, and the efficacy of its musically adapted version with children who have autism in a Chinese culture. This chapter will include the characteristics of autism, followed by descriptions of the social functioning of children with autism and pertinent techniques that have been used effectively to improve their social skills.

Autism

The first formal documentation of autism dates back to more than six decades ago when Leo Kanner, a child psychiatrist, described a group of children whose behaviors differed “markedly and uniquely from anything reported so far” by his time (Kanner, 1943, p.217). Many of these children were viewed as schizophrenic or mental retarded; however, Kanner noticed it was their innate inability to relate to the outside world, lack of language development, obsessiveness, and stereotype that kept them from interacting with the environment in an ordinary way. He named the condition “early infantile autism” as the symptoms were evident in early infancy (Kanner, 1944; Kanner, 1951). The criteria and description used to diagnose autism has been elaborated and modified since the disorder was first identified. In Hong Kong, children with autism are diagnosed under the criteria as laid down in the World Health Organization’s International Classification of Diseases (10th ed.) which defines Childhood Autism as an abnormal development with severe impairments in social interaction and communication, and a limited repertoire of interests and activities that is evident before age of three (Health, Welfare and Food Bureau, Hong Kong, 2005). Similar diagnostic criteria are adopted in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision) [DSM-IV-TR] (American Psychiatric Association, 2000). Autism, which is officially named as Autistic Disorder in DSM-IV-TR, falls under the category of

1 Pervasive Developmental Disorders. This category term implies that autism “involves a serious abnormality in the developmental process itself” (Davison et al., 2004, p.507) and the disturbances manifested by the affected individuals may change in form or intensity over time depending on the developmental level and chronological age. Impairments in social interaction displayed by people with autism may include a lack or inappropriate use of nonverbal behaviors such as eye contact, facial expression, and body language, a deficit in development of peer relationship, a lack of spontaneous sharing of things with others, and a lack of emotional reciprocity. They have low social awareness and would seem to be self-sufficient in their own world. Communication impairments may be manifested by a delay in, or a total lack of, spoken language. In those who have some speech, they usually have difficulty in initiating or sustaining a conversation. Some of them show echolalia or may vocalize vowels in a repetitive and meaningless manner which others cannot understand. There may also be a lack of developmentally appropriate make-believe play. In addition, the behaviors, interests, and activities of people with autism are often repetitive or stereotyped. These are apparent through their abnormal preoccupation with objects or activities, intense desire to maintain the exact sameness in routines, stereotyped motor mannerisms, and/or obsession on parts of objects (American Psychiatric Association, 2000; Gore, 2002). It is noteworthy that these symptoms can be exhibited in a wide variety of combinations in different severity. There can be great differences among people with autism. Therefore, the disorder is sometimes referred to as “autism spectrum” (Autism Society of America, 2005).

Social Deficits in Autism

Social skills of children with autism are by definition profoundly impaired. These deficits not only incapacitate the individuals’ social interaction with people, but also have an influence on other developmental areas, such as language, communication, and cultural competence (Garfin & Lord, 1986; Richer, 1978). Among various defining characteristics of the disorder, impairment in social functioning may be regarded as the most difficult to overcome even with training and treatment programs (Brownell, 2002). This difficulty is probably due to its pervasiveness in different contexts across the lifespan. As autism is a developmental disorder, the nature of social deficit demonstrated by the affected children tends to change with time. Sigman and Capps (1997) suggested that problems in social development could first be seen as early as 18 months of life. These infants initiate social interaction on rare occasions and are less responsive than normal children to those who try to engage them in play. Contrary to the stereotype of children with autism as unable to bond with parents, many of these children do develop an attachment to parents, although it is less pronounced than that of their normal counterparts (Howlin, 1986; Sigman & Capps, 1997). They show preference for interacting with mothers and fathers over strangers. However, parents of children with autism always need to work harder to make contact and share affection with their babies (Davison et al., 2004).

2 Even when some kinds of social relationship with parents or other adults develop, peer contact remains deficient in children with autism. During childhood, these individuals may have little, if any, interest in establishing friendships. They usually prefer to engage in solitary activity and seem unresponsive to other children who approach them. In addition, most of them do not show an ability of social imitation which is considered to be essential for acquisition of appropriate peer interaction. As they grow older, there may be a desire to be involved in interpersonal exchanges, but the lack of social skills often preclude them from forming normal reciprocal relationships. (American Psychiatric Association, 2000; Brownell, 2002; Howlin, 1978; Howlin, 1986; Schreibman, 1988). Another striking behavioral deficit exhibited by children with autism is their abnormal eye gaze. While early scholars considered avoidance of eye contact as one of the main characteristic in these children (Hutt & Ounsted, 1966; Rimland, 1964), more recent experts in autism tend to believe that this behavior is not universal among the population (Howlin, 1986; Mirenda, Donnellan, & Yoder, 1983). They suggest that children with autism do sometimes make eye contact, but it is the unusual quality of the gaze and their failure to combine looking with smiling that render their interaction with others difficult (Sigman & Capps, 1997). Like social relationships, patterns of eye gaze change with age. Older children with autism generally make more eye contact, but they may stare fixedly and inappropriately at people rather than developing a functional use of eye contact (Scheman & Lockard, 1979). Children with autism may appear aloof and unresponsive to people and things around them. They are sometimes suspected of their inability to express emotions. Nevertheless, children with autism are found to be as emotionally expressive as children with mental retardation or normally developing children by comparing the reports from parents of these three groups of children. The readily observable smiles, laughter, and temper tantrums provide further evidence that children with autism are capable of showing emotions, although the emotion shown may not be socially appropriate in the given situation. They are at the same time observed to be showing more negative emotions, such as sadness and fear, and fewer positive emotions, such as joy and excitement, than other children would do (Sigman & Capps, 1997). In addition to abnormal emotional expressiveness, inability to recognize emotional cues expressed by others is another affect-related impairment commonly displayed by children with autism. These children show no apparent evidence of discriminating between facial expressions, while they are able to differentiate different object categories (Sigman & Capps, 1997; Sigman, Ungerer, Mundy, & Sherman, 1987). They also have difficulty in picking up vocal cues that may help determine other people’s emotions. Even some high-functioning adolescents with autism are able to label facial expressions of different emotions, recognizing emotions expressed in the prosody of speech seems to be a tough task for them (Hobson, 1984; Sigman & Capps, 1997). These difficulties with emotional expressiveness and recognition experienced by children with autism may lead to their limited ability to understand and empathize with others’ feelings, which often in turn hinder them from developing relationships with people throughout their lives. Other behavioral problems frequently seen in, but not unique to, children with autism include attention deficit, hyperactivity, tantrum, rituals, and self-injurious behaviors (American Psychiatric Association, 2000; Snell, 2002). Despite the

3 considerable inadequacies, techniques have been developed to reduce the unusual behaviors of these children and to improve their social skills.

Pertinent Techniques

As children with autism have impairments that impede their ability to understand the rapidly changing social interactions on their own, information about the environment and relevant social cues should be provided in order to allow them to formulate appropriate responses (Gray & Garand, 1993). An accurate understanding of a given situation may enable the children to have positive social experiences which they seldom get. Grandin (1988) noted that people with autism tended to visual thinkers and learners. These individuals rely greatly on visual information when learning and processing information. They usually perform better in a task with written instructions than that with only verbal instructions. Based on this observation, educators and parents are advised to use visual methods of teaching and avoid long strings of verbal information to promote learning among the population (Grandin, 1995). In the light of this learning style of children with autism, a visually-based technique that helps establish social understanding as a prerequisite component to teaching social skills, termed “social stories”, was developed by Carol Gray in 1993 (Gray & Garand, 1993). A social story is a short story that objectively describes a social situation and identifies desired social skills. It is usually written by parents or professionals by following specific guidelines and format. Information in the story is based on a child’s actual experience and often includes where and when a situation takes place, who is involved, what is occurring, and why (Gray, 1998). The expected result of a social story intervention is improved social skills through improved social understanding (Gray, 1995). Quite an extensive amount of studies evaluating the effectiveness of social stories with children who have autism has been carried out since the technique was first developed, especially in the past five years. They showed high rates of positive results of the technique with children at various ability levels in different settings. Out of consideration for the extreme idiosyncrasies among children with autism, social stories are tailor-made with consideration of each child’s needs, abilities, interests, as well as attention span. For the same reason, how a social story is presented to a child can be as individualized as the story. There are three basic methods to introduce social stories to children with autism: as a printed story in a book format, as a story with accompanying audio cassette tape, and on videotape (Gray & Garand, 1993). Parents or professionals should select the optimum way of presentation according to the child’s unique abilities to allow maximum amount of concentration on and greatest understanding of the conveyed social information. An alternative method to present social stories to children with autism is through music (Brownell, 2002; Pasiali, 2004; Scott, Clark, & Brady, 2000). Music has actually been used with these children as a therapeutic tool for more than forty years. Its promising effects may partly be explained by the fact that many of these individuals are attracted to music. Thaut (1999) identified that music could be used as a carrier of nonmusical information such as academic concepts, world facts, self-help skill and social

4 skill information. The information can be arranged into chants or integrated into lyrics of songs. Although children with autism may exhibit defensiveness or abnormal sensitivity to some types of sounds due to the immature development of certain parts of the brain, many of them respond positively to music (Grandin, 1995). Brownell (2002) also noted the importance of differentiating between general auditory stimuli and musical auditory stimuli. However, since autism is a highly individualized disorder, it is definite that there would be individuals on the spectrum who have enormous aversion to auditory stimuli that makes musical interventions inapplicable. Nevertheless, music is preferred by a majority of the population and can be a great treatment modality for them. Another concern over the applicability of musical interventions with children who have autism is raised when considering the observation that these children are generally not aural learners. What eases this concern is the current knowledge about various functional areas of human brain that music centers are distinct from the receptive language centers (Wong, 2004). This implies information carried in a musical medium and spoken information are processed and stored in different areas of the brain. A person who has difficulty in understanding verbal information may be fine with sung directions (Grandin, 1988). Therefore, learning social information in a musical setting may facilitate attention during intervention, promote memorization of the social story information, and provide an avenue for recall of information for children who have preference for music (Brownell, 2002; Thaut, 1999). This facilitation probably results in enhanced social skills and appropriate behaviors. The purpose of the present study, thus, is to examine the effect of a musical presentation of social story on behavior modification in children with autism in home-based environments.

5 CHAPTER 2

REVIEW OF LITERATURE

This chapter will provide a review of literature pertinent to the purpose of this study. The first section will include research studies that have been carried out to investigate the characteristics and etiology of autism. The second section will provide a review of literature on the cause of social deficits exhibited by children with autism. Following is the third section that covers some of the techniques which have been used to remediate social skills of the population. The fourth section will provide a review of literature on music therapy and autism. Included in this section are studies regarding the musical responses of children with autism, and various applications of music therapy with these individuals. The fifth section will focus on a particular treatment technique, social stories, which is the basis of the present study. The method of developing social stories will be described in detail so that replication is possible. Also included in this section is a review of studies that have tested the effectiveness of social stories. The sixth and last section in this chapter will provide a rationale for the development of musically adapted social stories for use with children who have autism at home-based environments.

Research on Autism

Albeit differentiation of autism from mental retardation has been clarified since Kanner’s time, the comorbidity of these two disorders is common. According to DSM- IV-TR (American Psychiatric Association, 2000), there is a diagnosis of mental retardation concomitant with autism in most cases. Children with autism were once suspected to have high intelligence that was only masked by their symptoms (Kanner, 1944), however, studies have revealed that approximately 80 percent of these children score below 70 on standardized intelligence tests and function at a mentally subnormal level (Davison et al., 2004; Rutter, 1968; Steffenburg & Gillberg, 1989). Nevertheless, some of them show isolated areas of great talent, such as exceptional rote memory, spatial perception, or musical skills (Thaut, 1999). The unevenness of developmental delays in children with autism has provoked great interest among researchers in finding the etiology of this distinct disorder. The earliest theories placed an emphasis on psychological explanations. It was once believed that the pathological symptoms of autism were the result of an emotional trauma in early childhood, especially parents’ unresponsiveness or emotional maltreatment. However, there is no consistent empirical support for this postulation (Schopler, 1971; Thaut, 1999). It is now generally agreed upon that autism has a neurobiological origin. Since the 1960s, studies have shown the linkage between autism and the abnormal development or dysfunction of the brain (Damasio & Maurer, 1978; Golden, 1987; Haas et al., 1996; Hutt

6 et al., 1964; Tsai, 1989). Genetic factors play a role in some cases, while prenatal or perinatal brain damage resulted from the fragile-X syndrome, rubella infection, or tuberous sclerosis causes the autistic symptoms in other cases (Steffenburg & Gillberg, 1989). Recent research has put efforts to find out specific brain areas associated with the communication and behavioral difficulties experienced by people with autism (Davison et al., 2004). However, no single cause is yet identified for the etiology of this puzzling syndrome.

Cause of Social Deficits

Numerous researchers have tried to account for the deviant social behaviors observed in children with autism. Ferster (1961) found from his study that some particular kinds of behavioral deficits might be produced or maintained by the reinforcement the children received from their environments. For example, a continuous scream of a child may not be stopped until he is given some candies by his parents who find the noise annoying. Consequently, such reinforcement may cause a change in the frequency as well as in the form of the child’s behavior. A study conducted by Richer (1978) also indicated that the way in which parents and teachers responded to avoidance might have an effect of increasing the behavior because avoidance reinforced itself. DeMyer (1971) related the marked impairment in the use of nonverbal behaviors to the children’s perceptual limitations. It was found in her study that children with autism had difficulty in imitating body movements, which might probably be explained by their deficiencies in remembering visual stimuli or in transferring visual stimuli to their own motor system. Therefore, these children are not able to make use of the nonverbal communication of others to respond reciprocally as expected, and this makes them seem unresponsive to people’s initiation of interaction. Volkmar (1987) concluded from his observations that deficits in eye gaze/contact might “simply be a manifestation of the child’s lack of interest in the environment and difficulty in processing social and other kinds of information” (p.48). Howlin (1978, 1986) believed that impairment in social interaction was not due to the children’s unwillingness to be involved in social situations; rather, it was more attribute to their inability to do so. Their failure to understand the multiplicity of roles involved in social protocols is likely to make these children appear aloof and withdrawn. Wing (1978) had a similar view on the low sociability among children with autism. She contended that the social avoidance and poor eye contact of these children could be seen as arising out of the impaired cognitive aspect of social communication on a verbal level as well as a nonverbal level. They seem to lack a mechanism which helps them make sense of the environment. Thus, they may withdraw from situations that they cannot comprehend in order to avoid the possible distress or over-arousal. More recently, some researchers have proposed that the social dysfunctions exhibited by children with autism may be explained by their lack of “theory of mind.” “Theory of mind” essentially refers to an understanding that other people have their own beliefs, desires, feelings, and intentions that may be different from one’s own. It is suggested that this ability is largely independent of intelligence and would normally

7 develop before age of five among typically developing children (Davison et al., 2004). Being able to employ a theory of mind is crucial for understanding social situations in everyday life. However, several studies have revealed that there seems to be a specific cognitive deficit that prevents the development of theory of mind in children with autism (Baron-Cohen, Leslie, & Frith, 1985; Baron-Cohen, Leslie, & Frith, 1986; Frith, 1989). This deficit results in the children’s limited awareness of other people’s mental states, difficulty in understanding others' expectations, and inability to predict others’ words or behaviors in a social context. Even a small minority of children with autism can employ a theory of mind; they are still subject to a deficit in social understanding but at a higher level of complexity (Baron-Cohen et al., 1986).

Social Skills Techniques

Studies have found beneficial effects on social skills acquisition by children with autism in integrated environments (Harris et al., 1990; Odom, Hoyson, Jamieson, & Strain, 1985), yet social interactions between these children and other people in the same occasion would not spontaneously occur unless some kind of structure and scaffolding are provided (LeGoff, 2004; Myles, Simpson, Ormsbee, & Erickson, 1993; Roeyers, 1996). Therefore, based on the current understanding of the nature of social difficulties displayed by children with autism, a number of intervention techniques have been developed to foster their social competence. These interventions can generally be classified to five categories: direct skills instruction, antecedent prompting, peer- mediated approach, peer tutoring, and theory of mind (Rogers, 2000; Simpson, Myles, Sasso, & Kamps, 1991). Direct skills instruction is the earliest technique employed to promote social skills in children with autism. Interventions using this technique usually involve identification of specific skills needed to be addressed, task analysis of the skills, and teaching of skills to target children (Rogers, 2000). The efficacy of these interventions has been well studied and documented. Mesibov (1984) assessed whether a social skills training group, which aimed to teach fifteen individuals with autism essential social skills, could produce improvements in their social functioning. Teaching techniques used included modeling, coaching, and role-playing. Results showed that the participants had made progress in their selection of relevant topics, conversational skills, and perceptions of themselves after the three-month program. In a couple of similar studies, the validity of social skills group was demonstrated as well (Kamps et al., 1992; Williams, 1989). Generalization of the learned skills to other settings and situations may be possible through the use of direct instruction. Koegel and Frea (1993) found that teaching children with autism pivotal social skills not only rapidly improved their treated behaviors, but also their untreated social behaviors. Researchers have explored variants of the technique of direct skills instruction to achieve maximum effects over the years. For example, Koegel, Koegel, Hurley, and Frea (1992) taught children with autism to self-monitor the quality of their social interactions. Reinforcement would be given for correct self-monitoring responses. Results revealed that this self-management training improved responsiveness to verbal initiations from

8 others and concomitantly reduced disruptive behaviors which were not targeted on in the study. The same strategy was also used successfully to increase initiations by children with autism and their interaction time with peers (Morrison, Kamps, Garcia, & Parker, 2001). Other innovative strategies such as video modeling, group discussion, and appreciation of humor have received empirical support as well (Mesibov, 1984; Nikopoulos & Kennan, 2003). In order to foster social skills in a more natural context, researchers have used the technique of antecedent prompting to increase interaction attempts made by children with autism. Gunter, Fox, Brady, Shores, and Cavanaugh (1988) applied a “prompt and praise” procedure across dyads composed of a child with autism and a normally developing peer in a school setting. The peers were instructed daily to respond to all initiations made by the target children, avoid their own initiation, and be alert to various forms of initiations. During intervention conditions, the teacher would verbally prompt the target child to make social initiations to the peer within each dyad. If the child responded to the prompt and made an initiation, reinforcement would be given. Failure to respond appropriately would result in the use of a higher level prompting tactic by the teacher, which included modeling and verbal cue, and physical guidance plus verbal cue. Results indicated that the children with autism participated in this study increased their interactions with peers. However, only one of the two participants was able to generalize the improvement to a setting without verbal prompts. In a study employing a variant of this technique (Zanolli, Daggett, & Adams, 1996), children with autism were prompted to initiate and respond to typical peers during a “priming” session, which occurred immediately before the activity sessions. No prompts were given to the target children after the activity session had started. Results showed that spontaneous initiations made by the two participated boys with autism increased. This strategy is deemed optimum when no excessive teacher time is available during activities. Peer-mediated approach appears to gain popularity among clinicians, teachers, and researchers who try to remediate social deficits in children with autism. This technique uses typical peers as interventionists, who are usually taught to initiate play with perseverance to the target children with autism or to take a supportive role (Rogers, 2000). It has an advantage over the traditional method of skills instruction as it eliminates the need to develop procedures to transfer learning from adult partners to peer partners. Odom et al. (1985) increased the frequency of positive social interactions between preschool children with autism and their normally developing peers by teaching these typical peers social initiation skills. A token reinforcement system was used to reward them for appropriate initiations. However, no generalization to other classroom settings was noted. The positive impact of the peer-mediated intervention in a classroom setting was again demonstrated by Roeyers (1996). Although the typical peers in this study were not trained to use any techniques nor were they told how to play with the target children with autism, they were prepared for the interaction opportunities by receiving information on the autistic symptoms and being shown what kind of behaviors they could expect. Results showed significant improvements in the social behaviors of the target children. Several gains were also generalized to interactions with unfamiliar typical peers who were not involved in the study, to interactions with other children with autism, and to the large school setting.

9 Kamps, Potucek, Lopez, Kravits, and Kemmerer (1997) investigated the use of peer networks to improve social interaction for children with autism. The AB design of this study revealed that having a group of two to five typical peers as a support network during a structured activity increased interaction time between target children and their peers. A similar strategy termed “Circle of Friends”, which aims to promote social inclusion by establishing a friendship group for an isolated child with autism, was also found to be effective in increasing the frequency of social interactions among the two groups of children (Barrett & Randall, 2004). Peer tutoring is another successful technique involving typically developing peers. Blew, Schwartz, and Luce (1985) used one-to-one peer tutoring to teach community- based skills to children with autism. Each of the selected functional community skills was first task analyzed to a multi-step adaptive skill sequence. The typical peers were then taught the steps of each behavioral sequence and practical teaching techniques such as modeling, prompting, and cuing. Observational data indicated that the target children mastered at least two of the three sequences taught by a peer. In a more recent study, the effects of peer tutoring versus traditional teacher-led instruction on reading performance of three children with autism were compared (Kamps, Barbetta, Leonard, & Delquadri, 1994). During peer-tutoring conditions, target children were paired with peer tutors who had been trained for a thirty-minute reading curriculum. A reversal design revealed improved academic performance as well as increased social interaction in free time following the two peer-tutoring conditions. Since there is a growing body of research supporting “theory of mind” as an explanation for the social dysfunctions displayed by children with autism, interventions have been designed to attempt to remediate this specific cognitive deficit. Ozonoff and Miller (1995) reported a controlled group study of a social skills training program that focused on teaching adolescents with autism with normal IQ theory of mind principles. Pre- and post-intervention assessments showed that participants in the treatment group made substantial improvement on several false belief tasks, while no improvement was noted in the control sample. Although such a positive change in theory of mind performance after treatment was observed, generalization of the skills did not extend to other social situations. The authors believed that it might be the specific task rather than the ability itself was taught. Nevertheless, this was the first study to demonstrate that some aspects of theory of mind impairment can be helped by proper training. It is encouraging to see such a variety of intervention techniques have been developed to advance the social functioning of children with autism, however, treatment option needs to be carefully chosen to adapt to the specific needs and developmental level of each child (Howlin & Rutter, 1987).

Music Therapy and Autism

Numerous references have been made to the heightened interest and unusual response to music displayed by individuals with autism when reviewing literature on the disorder. It is the empirical evidence that music can be an engaging and motivating stimulus for the population validates the value of music therapy in the treatment of

10 children with autism. Researchers have developed different models of music therapy and continued to explore new strategies for effective intervention with these clients. This section will first provide a review of literature related to the musical abilities and sensory preferences of children with autism, followed by studies examining the use of music with the affected children.

Musical Responses of Children with Autism

In spite of the extensive impairments, children with autism often show extraordinary abilities in specific areas, including their remarkable capability for and responsiveness to music which are frequently mentioned in the literature. As early as in 1943 when Kanner first identified the syndrome, the unusual musical capacity of these children was noted, such as their ability to sing many tunes accurately and discriminate between symphonies at an extremely early age (Kanner, 1943). Rimland (1964) even included unusual musical capabilities as one of the diagnostic criteria for autism, although it is now no longer listed as a criterion in DSM-IV (American Psychiatric Association, 2000). Sherwin (1953) investigated the reactions to music of children with autism and noted their “unusual interest in, unique response to, ability for, or production of, music” (p.823). The children in his study showed fondness for music through their strong interest in singing, playing the piano, and listening to music for a long period of time. On top of that, they demonstrated a strong memory for melodies, an exceptional acuity of pitch production, a remarkable repertoire of classical music selections, and a preference for singing over speech. For those who were verbal, they might say words in a singing manner when they spoke. O’Connell (1974) coined the term “autistic musicality” to describe the outstanding musical talent in an otherwise low-functioning child with autism whom he worked with for four years. The child had absolute pitch and could play familiar tunes in any keys with appropriate chord accompaniment to the melody on the piano before receiving any formal musical training. He could also memorize every single note of a piece, including those notes inside the texture of the music. At the same time, however, some typical characteristics of autism such as difficulties in understanding abstract concepts and concentration problems were found in this unconventional music student. Albeit this may not be a common case in the autistic population, what draw attention is the possible astounding musical capabilities in these children when compared to their weaknesses in other performance and behavioral areas. In addition to the anecdotal reports, some researchers have provided empirical evidence to the musical abilities of children with autism. Frith (1972) analyzed and compared spontaneous sequences of colors and tones produced by normal developing children, subnormal children, and children with autism. Results revealed that the degree of complexity in the produced tone sequences did not distinguish children with autism from the control groups. He also noted the tunes played by children with autism on a xylophone were more complex and more original than their color sequences, which suggested that these children were often musical and could perform better in a musical modality. Similar results are reported in some other studies. Children with autism are able to perform as well as or even better than the age-matched normal children who have

11 considerable musical experience in a task of imitating tones (Applebaum, Egel, Koegel, & Imhoff, 1979). In an experiment by Thaut (1988), children with autism performed significantly better than children with mental retardation in musical improvisations. Albeit some individuals with autism show an aversion to general environmental sounds, they frequently have positive responses to or even register a preference for music. During his two-year observation on twelve children with autism, Pronovost (1961) found that these children often showed great interest in musical sounds in comparison with their responses to other environmental stimuli. It is also indicated in a couple of studies that children with autism prefer musical auditory stimuli over visual stimuli, in contrast with normal children who response equally to the two sensory stimuli (Kolko, Anderson, & Campbell, 1980; Thaut, 1987). Blackstock (1978) found that children with autism preferred the sung version rather than the spoken version of songs. In other words, they exhibited a preference for musical materials over verbal materials. Regarding the musical responses of children with autism, it can be concluded that many of these children respond more frequently and appropriately to music than to other auditory stimuli. Many of them also perform unusually well in musical areas as compared with most other areas of their behavior (Thaut, 1999). This unusual response to music among the population lays a sound base for the use of music in treatment of autism.

Music Therapy with Children with Autism

According to the statistical profile announced by American Music Therapy Association [AMTA] in 2005, people with autism are one of the populations most frequently served by music therapists (AMTA, 2005a). The association also outlines the benefits of this allied health profession for individuals with the disorder (AMTA, 2005b). Dr. Temple Grandin, who herself was diagnosed as having autism as a child, is supportive of music therapy and recommends it in her writings (Toigo, 1992). Empirically, a meta-analysis regarding music in intervention for children and adolescents with autism conducted by Whipple (2004) indicated that all use of music in treatment with this population had been effective. The positive results were obtained regardless of age of participants, music used, treatment methodology, or professional qualification of the music provider. Supported by the finding of this study and the statistical facts, music appears to be a powerful means of developing potentials of people with autism. As early as more than four decades ago, the use of music therapy with children who have autism has been recorded. Goldstein (1964) reported a case study on an eight- year-old girl with autism. Music therapy activities specially designed for this child included speech dynamics, singing, dancing, movement to music, and art. The goals were to increase her attention span, tolerance level, body awareness, and interpersonal social skills. After six months of music therapy intervention, an evaluation done by a psychologist noted a remarkable progress in her goal areas which allowed the child to prepare for beginning school experience. In additional to the non-musical goal areas addressed in the above study, Thaut (1999) and Whipple (2004) suggested that music therapy may also focus on the following areas: 1. Improve fine and gross motor coordination 2. Develop self-concept 3. Develop verbal and nonverbal communication

12 4. Alter or reduce ritualistic, repetitive, and self-stimulatory behavior patterns 5. Reduce anxiety, temper tantrums, and hyperactivity 6. Train sensory perception and sensorimotor integration 7. Improve group participation and facilitate learning 8. Improve self-care skills and symbolic play These fascinating benefits from music therapy are generally substantiated by empirical research (Hollander & Juhrs, 1974; Mahlberg, 1973; O’Connell, 1974; Saperston, 1973). Previous successful use of music with children who have autism has spawned further studies on the effects of various music therapy techniques in treatment of the population. The most frequently studied goals and objectives of music therapy intervention for children with autism in recent research can be grouped into two broad areas: communication/language and socio-behavioral. These areas are in accordance with the goal areas most frequently addressed by music therapists in real life settings (Kaplan & Steele, 2005).

Music therapy with communication/language skills in autism. Several researchers have examined various music-embedded techniques to improve communication and language skills of children with autism. Edgerton (1994) investigated the effectiveness of improvisational music therapy on communicative behaviors of children with autism. Results revealed that the technique was effective in eliciting and increasing communicative behaviors in the eleven children participated in the study. They showed significant gains in four musical communicative modalities, including tempo, rhythm, form, and pitch, across ten music therapy sessions. A significant relationship between increases in musical vocal skills and increases in nonmusical speech production skills was also obtained. This finding implied that communication through music might bypass the speech and language barriers possessed by individuals with autism. The use of melodies and rhythmic patterns in verbal instructions may facilitate learning and aid memory. A study by Buday (1995) found that the number of signed words and the number of spoken words correctly imitated by ten children with autism were significantly higher when using sung text rather than spoken text. In a more recent study, the effects of emphasized speech and music therapy on echolalic behaviors displayed by children with autism were compared (Gore, 2002). Emphasized speech aims to assist people in overcoming language learning impairments by emphasizing and prolong crucial acoustic cues in an ongoing speech. In each session, communication was established using different methods to elicit a temptation to communicate from the child participant. Findings of this study indicated a remarked increase in echolalia in two of the five participants when emphasized speech was used as a treatment. Though three other participants exhibited a decrease in the frequency of echoes when music was implemented, music helped build rapport and increased communication between the children and the therapist. Gore suggested using both emphasized speech and music therapy techniques to increase communicative attempts from these children. The results of these studies warrant music as an effective tool to ameliorate communication skills of children with autism.

Music therapy with social skills in autism. Another area in which music therapists could achieve success is in the development of social skills and appropriate

13 social behaviors among children with autism. The earliest music therapy study which specifically addressed social skills of the population appeared in 1969. Stevens and Clark (1969) evaluated the changes in social behaviors of five boys with autism following a series of eighteen music therapy sessions. Pretest and posttest data showed that participants improved significantly on nature and degree of relationship to adult, communication, and drive for mastery. Although several limitations were associated with the chosen design, this study pioneered systematic research which applied objective methods of control, observation, and data reporting on social effects of music therapy with this population. In another study using a pretest/posttest design, music was used to increase socialization by arousing the interest of participants and lessening the threat of failure (Hairston, 1990). Findings indicated significant increases in time spent observing teacher, appropriate play, and acceptance of physical contact exhibited by a group of children with autism and mental retardation who received daily music and art therapy for five weeks. Music has been found to be effective in modifying behavioral problems displayed by individuals with autism. Results from a study by Burleson, Center, and Reeves (1989) showed that background music could reduce off-task behaviors and facilitate task performance of children with autism. Orr, Myles, and Carlson (1998) investigated the impact of a somewhat new technique, rhythmic entrainment, on problematic classroom behaviors of a girl with autism. Rhythmic entrainment is a method that uses music to aid in relaxing by introducing externally produced rhythms which are specifically designed to re-entrain the body to its natural rhythmic patterns (Strong, cited in Orr et al., 1998). Observational data revealed that the intervention was effective with the participant. Contingent applications of music may play a role in decreasing undesirable behaviors. Dramatic reduction in aberrant, repetitive vocalizations exhibited by an adolescent boy diagnosed with autism was noticed with provision of contingent use of music played through lightweight headphones (Gunter et al., 1993). Similarly, the same technique can be applied to other situations with individuals who have a strong affinity for music. Dellatan (2003) examined the contingent use of music listening with a five- year-old boy with autism who had severe food refusal problems. Previous treatments by behavioral psychologists and therapists had been unsuccessful. Results indicated a significant decrease in the food refusal behaviors as well as an increase of food consumption quantities after the introduction of contingent music intervention. Since human beings have an innate preference for music (Standley & Madsen, 1990), it may be used to create a cozy platform on which interaction between two groups of people is encouraged. Wimpory, Chadwick, and Nash (1995) successfully used Musical Interaction Therapy, which uniquely synchronized live music to adult-child interactions, to increase the interaction of a three-year-old child who had autism with her mother. The participant made improvements in the use of social acknowledgement, eye contact, and initiations of interactive involvement after receiving the intervention. A two- year follow-up confirmed that these positive changes were sustained. Moreover, a couple more studies validated the use of music to foster social play between children with disabilities and their typically developing peers (Gunsberg, 1988; Humpal, 1991). Although the findings of these studies cannot be construed as being representative of every child with autism, the general belief that music is a special tool to work with the

14 population is supported by a substantial amount of empirical evidence. In fact, music therapy in treatment of children with autism has also been accepted in other countries such as Finland and Germany (Evers, 1992; Kielinen, Linna, & Moilanen, 2002).

Social Stories

On top of behavioral techniques and music therapy, a method that is increasingly suggested for improving social skills of children with autism is the use of social stories. The rationale of social stories is based on the growing body of empirical evidence which reveals these affected children’s innate inability to “read” social cues and perspectives of others, and their difficulty in interpreting the meaning of an event as a whole from diverse pieces of information (Gray, 1998). As first described by Gray and Garand (1993), social stories are “short stories that describe social situations in terms of relevant social cues and often define appropriate responses” (p.1). In other words, social stories are designed to provide children with autism with the information they are missing (Kuoch & Mirenda, 2003). The technique is used to assist these individuals in understanding and interpreting challenging or confusing social situations by providing them with important social cues and increasing their awareness and understanding of the who, what, when, where, and why of social situations (Sansosti, Powell-Smith, & Kincaid, 2004). Appropriate responses are expected to be formulated on their own after having an accurate understanding of situations.

Developing a Social Story Intervention

Gray (1995, 1998) suggested a couple of steps in preparation for generating a social story. The first step is to determine the topic on which the entire story will focus. It can be a specific social skill or a social situation that continues to be difficult for a child even with interventions. Other possible topics are future situations such as new social skills or novel social situations. Once a topic is identified, the second step involves gathering information. Detailed information is usually obtained through direct observations and interviews with relevant individuals. Information such as typical sequence of events, relevant cues, the child’s abilities, interests and responses to the given situation are important. Last but not least is the perspective of the child with regard to the target skill or situation. Gray (1993, 1995, 1998) has consistently emphasized that the child’s perspective is the most critical factor in writing an effective social story. The more thorough an author understands the child’s perceptions and feelings, the more likely he or she will provide accurate information that is useful to that child. Beginning with the child’s perspective, an author is able to incorporate essential information into an individually tailored social story. Each social story is written within the child’s comprehension level, using vocabulary and print size appropriate for his or her ability and other personal characteristics (Gray & Garand, 1993). Table 1 outlines the four basic types of sentences used in a social story, along with an example for each. Each type of the sentences serves a specific function. A social story does not have to contain all four sentence types. An author can use a combination of the four different types of

15 sentences to develop a story that addresses the objective set for the child most effectively. However, the proportion of descriptive, perspective, directive, and control sentences in a whole social story needs to conform to the “social story ratio” of 2 to 5 descriptive and/or perspective sentences for every 0 to 1 directive or control sentence (Gray, 1998). This ratio is meant to ensure the emphasis of each story is to describe more than to direct.

Table 1 Basic social story sentences Type of sentence Function of sentence Example 1. Descriptive objectively define where a situation “My school has occurs, who is involved, what they many rooms.” are doing, and why 2. Perspective describe a person’s internal states, “The children are e.g. a person’s physical state or desire, hungry.” perceptual perspective, thoughts, feelings, or beliefs and motivations 3. Directive directly define what is expected as a “I will try to talk response to a given cue or situation quietly inside.” 4. Control written by a child, usually through “Lunch lines and the use of analogies, to identify turtles are both strategies the child may use to recall the very slow.” information in a social story, reassure him- or herself, or define his or her response References. Brownell, M. D. (2002); Gray, C. A. (1998).

In order to provide greater opportunity for children with autism to determine their own social response to a given situation, directive sentences should be written in a positive, suggestive tone rather than as a command. Phrases begin with “I will try to …” or “I will work on …” are preferred to a directive sentence begins with “I should …” or “I will ….” Similarly, terms like “always” or “will”, which may result in literal and rigid interpretations, should be avoided in favor of “usually” or “sometimes” (Gray, 1995). Once a social story is created, it may be read by the child or to the child. The review schedule is dependent on the topic of the story. For example, a story describing a daily or weekly event would generally be reviewed just prior to that event (Gray, 1998). Gray and Garand (1993) have suggested three basic ways of social information presentation to children with autism possessing different reading and comprehension skills. For independent readers, a printed social story book may be adequate. For children who cannot read independently or who enjoy audio tapes, the story may be recorded on a cassette tape with a bell to signal page turns. The child may then read the story book with

16 the accompanying cassette. For those who are unable to read or who enjoy watching television, the pages of the book can be filmed onto a videotape. Despite the above approaches are frequently used to introduce social stories to children with autism, parents or professionals are encouraged to be creative on customizing how information should be presented so as to increase a child’s motivation to attend to a social story (Gray, 1998). Parents and professionals may also pair social stories with a simple reinforcement system or a contingent activity program to enhance the effectiveness of the intervention (Simpson, 1993). The use of illustrations in social stories was not recommended when the technique was first developed due to the possible distraction and inaccurate interpretation of the situation based on the illustrations (Gray & Garand, 1993). However, while more studies support the purport of visual learning strengths of people with autism, the originator of this technique stated in a more recent article that “social stories …… are visually dependent strategies that require parents/professionals and students with high-functioning autism/Asperger syndrome to communicate concepts and ideas with the support of written words, simple illustrations, symbols……” (Gray, 1998, p.170). Although illustrations may add interest and visual support for the presented concepts, it is advised that all illustrations used should be marked by simplicity to avoid children focusing on irrelevant details. Based on the work of Gray (1995) and Gray and Garand (1993), Swaggart et al. (1995) have developed a step-by-step program for writing, implementing, and evaluating the effectiveness of social story interventions. This program is comprehensive and can be easily adapted for future research on a variety of children and adolescents with autism. 1. Identify a target behavior or problem situation for social story intervention. 2. Define target behavior for data collection. 3. Collect baseline data on the target social behavior. 4. Write a short social story using descriptive, directive, perspective, and control sentences. 5. Place one to three sentences on each page. 6. Use photographs, hand-drawn pictures, or pictorial icons. 7. Present the social story to the child and model the desired behavior. 8. Collect intervention data. 9. Review the findings and related social story procedures. 10. Program for maintenance and generalization (pp.14-15).

Effectiveness of Social Stories

Social stories are basically applicable to any situations in school, home, and community settings (Gray & Garand, 1993). A number of clinical case studies and scientific research have been carried out in these environments to examine the efficacy of the technique on children with autism or other subcategories under the umbrella of Pervasive Developmental Disorders who have a variety of social and behavioral needs.

The use of social stories in school settings. In the first such study, a combined intervention of social stories and behavioral social skills training was used to teach appropriate social behaviors to three children who had moderate to severe levels of

17 autism. These children were placed in a restricted educational setting due to the severity of their behaviors. One of the participants was an 11-year-old girl. Two social stories were written for her aiming at increasing appropriate social greeting and decreasing aggressive behavior respectively. Results indicated an increase from 7% to 74% in the girl’s appropriate greeting behavior and a decrease from 9% to 0% in her aggressive behavior following the introduction of social stories. The other two participants in this study were two 7-year-old boys. Target behaviors for them were sharing, parallel play, aggression, screaming, and grabbing. An individualized social story was written for each of them though they had the same target behaviors. Observational data from baseline and treatment periods showed that the first boy demonstrated increases in sharing (0% to 22%) and in parallel play (80% to 94%), and decreases in aggression (30% to 6%) and in screaming (100% to 56%). Similar results were observed for the second boy who demonstrated an increase from 0% to 35% in sharing, an increase from 80% to 94% in parallel play, a decrease from 80% to 0% in aggression, and a decrease from 100% to 35% in grabbing (Swaggart et al., 1995). This study validated the use of social stories on increasing appropriate behaviors and reducing behavioral excesses with this population in a classroom setting. The use of social stories with children who have autism in other school situations has also been studied. Kuttler, Myles, and Carlson (1998) developed a social story intervention program for a twelve-year-old boy who attended a residential school for children with special needs. He was diagnosed with autism, Fragile X syndrome, and intermittent explosive disorder. Two social stories were introduced to him to reduce his precursors to tantrum behavior during morning work time and lunchtime in a self- contained classroom. Data revealed a marked decrease in precursors to tantrum behavior during social story intervention. Noteworthy, the target behaviors were extinguished to zero on all days during morning work time and on half of the days during lunchtime when social stories were available to the participant. Other disruptive behaviors may be improved through the use of social stories as well. In a study by Scattone, Wilczynski, Edwards, and Rabian (2002), results showed that all three participants exhibited a reduction in their respective disruptive behaviors, which included chair tipping, staring, and shouting, with social stories interventions. The technique has been used successfully to address poor eating manners that occur at school. A five-year-old boy with autism improved his eating behaviors when social story was implemented. There was a decline in the frequency of his throwing up food and putting hands inside pants during snack time and lunchtime (Kuoch & Mirenda, 2003). In a similar study by Bledsoe et al. (2003), a social story program individualized for an adolescent with Asperger syndrome resulted in a decrease in the number of food and drink spills and an increase in the frequency of appropriate mouth-wiping during lunch at school. One of the characteristics exhibited by children with autism is their marked impairments in social interaction. Several studies have provided insights into the relationship between a social story intervention and social behaviors occurring among students with autism and their peers. Norris and Dattilo (1999) developed three social stories for an eight-year-old girl with autism who attended an inclusive second-grade classroom to reduce her inappropriate social interactions during lunchtime such as talking or singing to herself. In an effort to teach the participant new patterns of behaviors,

18 appropriate alternative behaviors were also included in the stories. Results of the study revealed a positive, though somewhat delayed, effect of the social story intervention. Specifically, there was a 48% decrease in inappropriate social interactions with her peers at lunch. However, the level of appropriate social interactions did not change at all even with social story intervention. The authors speculated that perhaps because the story was read to the participant prior to lunch, it was not powerful enough to establish the desired behaviors. They suggested the use of a direct instructional intervention during lunch to increase the acquisition of social skills. How to play appropriately with peers may be another social challenge to children with autism. Kouch et al. (2003) and Barry et al. (2004) tested the effectiveness of social stories on teaching these children play skills in their classrooms. Both studies found support for the use of this intervention. Children participants demonstrated longer time of appropriate play and better rule-following. Based on the promising results of the existing research, further investigation should be carried out to explore the potential use of social stories in other peer interaction opportunities and school situations.

The use of social stories in home settings. Aside from being used extensively at school, social stories have been found effective in managing behavior problems in children with autism in home settings. Lorimer et al. (2002) examined the efficacy of social stories to reduce tantrum behaviors in a five-year-old boy with autism. Two social stories were created for the participant and each story was read to him twice a day. Observational data indicated that the frequency of tantrum behaviors occurred at home decreased significantly upon implementation of social stories. However, these behaviors jumped back to levels similar to those displayed prior to the introduction of social stories when returning to baseline conditions. This reversal implies that social stories need to be continually implemented in order for desired behaviors to be observed in the participant. Similarly, the technique was used to decrease social inappropriate behaviors for a seven-year-old boy with Asperger’s syndrome in the home environment (Adams et al., 2004). The target behaviors were four frustration behaviors the participant exhibited during homework time, including crying, screaming, falling from chair, and hitting. There was an overall decrease of at least 48% in their frequency of occurrence in all four behaviors from the first phase to the final phrase of the study. Additionally, carryover effects were noted. According to the participant’s classroom teacher, the inappropriate behaviors targeted at home decreased at school as well without direct intervention. Kuoch and Mirenda (2003) used a social story intervention to teach sharing to a three-year-old boy diagnosed with autism at the age of two. The participant would cry, yell, and become aggressive when asked to share toys or other possessions with his older brother at home. After an individualized social story was introduced, there was an immediate decrease in the rate of problem behaviors and that generalization of sharing behavior also occurred. Incorporation of social stories in other approaches may be beneficial in improving behaviors displayed by children with autism in home settings. A behavioral specialist evaluated the use of a social story as part of a conventional behavioral intervention with a four-year-old boy who presented behavioral problems surrounding sleep and bedtimes (Moore, 2004). The participant was diagnosed with autism, severe learning disabilities, and receptive speech and language delay. He would only sleep in his parents’ room upon

19 his mother’s close presence, and took more than an hour to fall asleep. He would wake several times in the night and demand milk from his mother, and would wake very early in the morning. The poor quality and quantity of his sleep was unsurprisingly connected to unmanageable behaviors throughout the day. After a thorough assessment, a social story book was created and read once to the participant routinely before bedtime. Reinforcement was used in the program to increase his motivation for behavioral change. Qualitative results showed positive effects of the intervention. The participant was willing to sleep in his own bed after the introduction of social story. His mother also felt that his challenging behaviors were better than before.

The use of social stories in community settings. As suggested in the original article by Gray and Garand (1993), social stories can be used to introduce changes and new routines. Ivey, Heflin, and Alberto (2004) used social stories to prepare three children with Pervasive Developmental Disorder Not Otherwise Specified for novel events within the routine setting of their weekly speech-language therapy sessions which occurred in an outpatient speech-language pathology clinic on a children’s hospital campus. The reversal design of this study evidenced that the technique was effective in enhancing participation in novel activities. Specifically, there was a 15% to 30% increase in participation for all three participants. Knowing this benefit may allow people who work with children who have autism; including parents, teachers, and babysitters, to better prepare the children for opportunities for participation, learning, enjoyment, and interactions in various situations and events. Although the social story originators suggested that “social stories are most likely to benefit students functioning intellectually in the trainable mentally impaired range or higher who possess basic language skills” (Gray & Garand, 1993, p.2), it is noteworthy that more than half of the participants in the studies discussed above fell within the spectrum of having moderate to severe autism or other types of pervasive developmental disorders and have poor language skills. In other words, these research studies evidenced the successful use of the technique with more severely challenged children when appropriate modifications are made. Interestingly, some researchers have even extended the use of social stories to normal children. Burke, Kuhn, and Peterson (2004) examined the efficacy of a social story in reducing disruptive bedtime behavior and frequent night waking in four normal children. Instead of using individualized stories like those for children with autism, one same story was read to the participants by their own parents before bedtime. Parent sleep diaries indicated that the children had an average decrease of 78% in frequency of disruptive bedtime behaviors from baseline to intervention. Night waking, which was a problem for two out of the four children during baseline, was not a problem anymore after the social story was introduced. The results of this study may institute an exploration among researchers and clinicians to further extend the populations with which social stories can be used. Despite social stories are developed and become popular among English-speaking cultures, the technique has also been used in countries outside America and Britain. For example, two researchers in Sweden used a social story to explain the procedures of a dental treatment to a nine-year-old boy with Asperger’s syndrome (Backman & Pilebro, 1999). As far as in the Oriental countries, the effectiveness of social stories has been studied. Hung and Luk (2001) investigated the effect of social stories with children who

20 have Asperger’s syndrome in Hong Kong on reducing their social behavioral problems. The eight participants in this study were divided into three groups according to language abilities: poor expressive and receptive language skills, poor expressive but fair receptive language skills, and good expressive and receptive language skills. Each of the participants received ten individual social story sessions. Observational data showed that positive results were obtained with the group of children who had poor expressive but fair receptive language skills. However, behavioral problems of the children in the other two groups did not seem to improve even with social story intervention. In another study conducted in Hong Kong, four adolescent boys aged twelve to fourteen were taught to pay attention when others were speaking on class (Li, 2001). The attention-paying behavior was decomposed to three aspects including eye contact, proper body position, and keeping quiet. The researcher combined role-play and reinforcement with a social story presented in a video form. Results indicated that three out of four participants demonstrated improvement on at least one aspect of attention-paying behavior. Regardless of the countries where the discussed studies were carried out, they all employed traditional ways of social information presentation as suggested by Gray and Garand (1993). Some researchers have used unique approaches in presentation of social stories to children with autism in order to boost the little readers’ interest. For example, Hagiwara and Myles (1999) found that a multimedia social story intervention using visual stimuli and sound presented via computer program had positive effects and applicability for the population. Incorporating social stories as lyrics in songs is another novel way of presentation. Brownell (2002) compared the efficacy of a traditional presentation of social stories with musical adaptation of the stories to improve behaviors of four students with autism in a classroom setting. A social story was tailor-made for each participant. Original music was then composed to incorporate the sentences of the story as lyrics. Results, though highly variable, indicated that both traditional and musical social stories were effective in decreasing undesirable behaviors for all four participants. Noteworthy, for two of the participants, the frequency of their undesirable behaviors was lower during the musical adaptation of their respective social stories than during the traditional way of presentation. The validity of using musical adaptation of social stories was further studied by Pasiali (2004). Instead of composing original music, Pasiali used a technique named “Piggybacking” to set the text of social stories to a tune familiar to the child participant. She examined the effects of these prescriptive songs on promoting social skills acquisition by three children with autism at home-based environments. Results of this study added one more piece of empirical evidence for the use of musical social stories. An ample amount of scientific evidence as well as anecdotal claims have been made for the use of social story technique with children who have autism. The rationale for integrating music with social stories stems from research supporting that individuals with this disorder often have an affinity for music. They may prefer musical auditory stimuli over verbal auditory stimuli (Blackstock, 1978) and visual stimuli (Kolko et al., 1980; Thaut, 1987). This sensory preference implies that using music as a carrier of social story information may promote intervention efficacy by enhancing attention and involvement of the children, aiding in comprehension, and allowing enjoyable repetitions (Brownell, 2002; Thaut, 1984). Another rationale comes from Buday (1995) who

21 concluded from her study results that musical presentation of information may enhance skill acquisition by children with autism over spoken version. Dr. Temple Grandin, who is an animal scientist diagnosed with autism, also suggests that musical instructions may be more effective than spoken instructions for these individuals (Grandin, 1988). Although she, and probably many other people with autism, relies heavily on visual thinking, melodies are the only things she can memorize without a visual image. She believes that a successful autism program should include a strong emphasis on musical activities. A final piece of support comes from the validity of using musical presentation of social stories established by Brownell (2002) and Pasiali (2004). However, as these studies were conducted in the American culture, their results may not be applicable in other cultures. Therefore, the purpose of this study is to examine the feasibility of musically adapted social stories to facilitate social learning and behavior appropriateness for children with autism in a Chinese-culture environment. The following research questions will be addressed: 1. Is the use of a traditionally read social story more effective in modifying the target behavior than the no-contact control condition? 2. Is the use of a musically adapted social story more effective in modifying the target behavior than the no-contact control condition? 3. Is there a significant difference between the efficacies of the two treatment types?

22 CHAPTER 3

METHOD

Participants

Participants in this study were four Chinese children, two males and two females, in Hong Kong. Their ages ranged from five to twelve years old. Each of these children had been diagnosed with autism. Selection was based on parental consultation and informed consent procedures. Only children who had no previous social story and/or music therapy interventions to remediate the target behavior identified for the present study were selected. Other criteria for inclusion were: (1) the child has no hearing loss; and (2) has exhibited a positive response to music and/or music therapy.

Design

An ABAC/ACAB counterbalanced design was used where the first and third components (A) represented the baseline conditions, the second component (B) represented the treatment condition “reading the story,” and the fourth component (C) represented the treatment condition “singing the story.” Participants were alternatively assigned to treatment order ABAC and ACAB as so to minimize any order effects associated with receiving one treatment condition or the other first (Brownell, 2002). Five days of data collection were taken place for each condition, with a total of 20 days for the entire study.

Procedure

The researcher contacted parents of children with autism by emailing and talking to advocacy groups which provided services for children with disabilities in Hong Kong. Parents who were interested in letting their children participate in the study had a phone consultation with the researcher to discuss the details of the study and identify an appropriate target behavior of their child for the purposes of this study. After five potential participants were selected, the researcher met with the parents in person during when they obtained and signed an informed consent. The first nine steps of the 10-step procedure developed by Swaggart et al. (1995) was used as a basis to create, implement, and evaluate a social story intervention program for each participant. The last step, involving the investigation of the effectiveness of generalization of a social story program, was excluded because it was beyond the scope of the present study. Step 1, which involved the identification of a target behavior, was basically completed during phone consultation with the parents. Target behaviors selected were problematic behaviors that occurred at home daily with a high frequency, and behaviors whose improvement could lead to increased interactions with family members or others, and/or additional social learning opportunities. Step 2 was to

23 operationally define the target behavior on which data would be collected. Data collection was scheduled during the time of the day when the target behavior was most likely to occur as identified by the parents. Step 3 entailed the collection of baseline data. A Canon MV300i digital video camera was set at the participants’ home during the time period of data collection. The video tape was then watched repeatedly by the researcher to ensure accurate data collection. Data were collected as frequency tallies or duration of the targeted behavior exhibited by the child participant, using a form that included the child’s name, the target behavior, and the operational definition of the target behavior. Through Steps 4, 5, and 6, an individualized social story book was made for each participant to address the target behavior. Following the guidelines for writing social stories (Gray & Garrand, 1993), a unique story was written at the reading level of the child as determined by the parents. Additionally, the social story ratio (Gray, 1998) of zero to one directive or control sentence to every two to five descriptive or perspective sentences was followed. Appropriate illustrations were created for each story using the Picture Master software. Next, the story and illustrations were printed on white paper with black ink using appropriate print size for the child. The rationale for using black ink on white paper instead of using color ink as in general children storybooks was to minimize distraction and keep the child focus on the presented concept (Pasiali, 2004; Swaggart, 1995). The story was then cut apart into separate concepts and placed on the bottom of black construction paper. One to three sentences were placed on each page so as to avoid an overload of information. Each page of the story was then stapled together in a book format. Subsequently, original music was composed for each social story using the text of the story as lyrics. Step 7 involved treatment phases after the completion of baseline data collection. The researcher visited each participant’s home and either read or sang the social story once to the child immediately prior to the data collection period in a secluded area or room at the home. Following presentation of the social story, the researcher left the home after setting a digital video camera for the purpose of intervention data collection. The camera was stopped and taken by the researcher when data collection period was over. Intervention data were then taken in the same manner as the baseline data (Step 8). A graphical representation of each participant’s data was made for visual analysis after all needed data were collected (Step 9). A series of paired-samples t-tests was performed in order to address the research questions. Approximately three weeks after completion of the last treatment phase, the researcher contacted the parents to check for follow up. The learning effect and maintenance after termination of the social story intervention program were discussed. In addition, the researcher went over the results of the child’s individual case study with the parents and the child participant to the extent of their understanding. Suggestions and recommendations to keep the frequency or duration of the target behavioral problems low were also made to the parents. An independent observer viewed 25% of the digital tapes for calculation of inter- observer reliability. For participants I and IV, whose target behaviors were recorded as durations, inter-observer agreement score was calculated by the following formula: (shorter number of seconds/longer number of seconds) X 100% (Alberto & Troutman, 2006). For participants II and III, whose target behaviors were recorded as frequencies,

24 the formula used to calculate inter-observer agreement was agreements/(agreements + disagreements) X 100% (Alberto & Troutman, 2006).

25 CHAPTER 4

CASE STUDIES

Case Study I

Background

Mike was a five-year old male diagnosed with autism and hyperactivity at the age of two. He lived with his mother in a single-parent family and would meet his father one to two times a week. Mike attended a preschool for children with special needs in the morning and a kindergarten for normal children in the afternoon prior to the summer vacation during when the present study was conducted. According to his mother, Mike was a high-functioning boy and he ranked number three in his class in the last examination in the kindergarten. Mike’s reading ability was at grade level. During the two years in the preschool for children with special needs, Mike received individual speech therapy once every two weeks for thirty minutes. He also received a thirty-minute individual occupational therapy session every two weeks and a forty-minute group occupational therapy session weekly. But he had never received music therapy service. Mike’s mother commented that her son enjoyed music. He went to bed with music and would sing songs he learned from school or from TV. Mike demonstrated a strong memory for music. He was able to sing a song with correct melody and words after listening to it for a few times. Mike exhibited some characteristics associated with autism including underdeveloped peer contact, delayed spoken language development, echolalia, and incorrect use of pronouns. He often repeated what was said to him immediately after a person finished a sentence or question. It is, perhaps, due to this echolalic behavior that he sometimes replaced “I” with “You,” and vice versa. Mike also displayed some behavioral problems frequently seen in children with autism such as tantrum, attention deficit, and hyperactivity. One of the biggest challenges his mother faced was having Mike sit properly for certain occasions. As described by his mother, Mike would not sit still for more than ten seconds. He rarely walked but ran and would sit with his head on the sofa at home. It was especially irritating to his mother when they watched television together. Mike’s hyperactive behaviors concerned his mother not only because of the appropriate manner he should have, but also his safety.

Target Behavior

The behavior targeted for this study was increasing proper sitting behavior during TV-watching time. Operationally, the behavior was defined as sitting with back straight up, not moving limbs around, and not moving feet and palms or clapping hands. The

26 duration of target behavior was recorded. The time Mike and his mother watched TV together before dinner every evening was scheduled for data collection. This thirty- minute time period was suitable for data collection as it was within their daily routine.

Implementation Procedures

After identifying the target behavior, procedures as outlined in the method section were followed. A social story entitled “Watching TV” was created to discuss the importance of sitting appropriately when watching television and the consequences of not doing so. An English translation of the original Chinese social story may be viewed in Appendix A. Original music was composed using the text of the social story as lyrics. The printed music may be found in Appendix B. Mike was assigned to the treatment order ABAC. Data collection lasted thirty minutes, from 7:00-7:30 p.m. A digital video camera was placed at a corner in the apartment with wide-angle lens to view the entire living room area where Mike would stay during this segment of time. During intervention periods, the researcher met Mike immediately before the scheduled data collection time. During condition B, the researcher read the social story to Mike while he would simultaneously read the story and follow the words with his finger. During condition C, the researcher sang the story to Mike with live guitar accompaniment. Mike would sing loudly along with the researcher as he held the storybook in hand. After meeting with the researcher, Mike started watching TV and the researcher left the apartment. Reliability data were collected by having an independent observer viewed 25% of the digital tapes. Mean inter-observer reliability across all four conditions was 88.63%

Results of Case Study I

Figure 1 depicts a visual representation of the data collected. It indicates an increase of the target behavior, proper sitting, from baseline during both treatment conditions. During the return from the first treatment condition to the second baseline condition, occurrences of the behavior decreased, but did not achieve the levels seen in the first baseline. Over the course of the two treatment conditions, a general upward trend in the duration of behavior can be seen. Furthermore, the target behavior occurrences were lower during the music condition than during the reading condition. A t-test comparing the first baseline condition to the reading condition (Research Question One) yielded a significant difference (p = .01) (See Table 2). When comparing the second baseline condition to the music condition (Research Question Two), a significant difference was also found (p = .04) (See Table 2).The final comparison between the two treatment conditions produced no significant results (p = .10) (See Table 2).

2000 Baseline 1 (A) 1800 Story Read (B) Baseline 2 (A) Story Sung (C)

1600

1400

1200

1000

800 Proper Sitting Sitting Proper 600

400

200

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Observation Days Figure 1. Duration of proper sitting (in seconds) exhibited by participant Mike by condition.

Table 2 t-tests for condition comparisons for participant Mike Comparison t df p A1:B -4.89 4 .01 A2:C -3.02 4 .04 B:C -2.15 4 .10

Follow-up

Following the completion of the final treatment phase, Mike often spontaneously sang the social story song written for him. When asked by his mother what the song was about, Mike was able to verbalize the contained social information, though he might not be able to follow the suggestions in the song every time. A follow-up three weeks after the final observational day indicated that the occurrence of jumping around and fidgeting during TV-watching time remained low and instances of proper sitting were often observed. Mike’s mother was pleased with the results and believed that her son’s participation in the study was beneficial.

28 Case Study II

Background

Toby was a four and a half year old male diagnosed with autism at the age of two and a half. Toby attended a preschool for children with special needs in the morning and a kindergarten for normal children in the afternoon prior to the summer during when this study was conducted. Toby’s reading ability was at grade level. During the two years in the preschool for children with special needs, Toby occasionally received individual and group speech therapy. He also received a sixty- minute individual occupational therapy session once a while. Moreover, his mother paid for a private speech therapist to provide individual speech therapy once every two weeks at their home since four months before the present study began. Each session lasted for an hour. However, Toby had never received any music therapy services. According to Toby’s mother, her son enjoyed music. He liked to listen to children song CDs and often sang along. He would also sing the songs he had heard before. Toby displayed many typical characteristics of autism such as underdeveloped peer relationships, difficulty coping with changes in environments or routines, repetitive hand movements, attention deficit, and idiosyncratic language. He often engaged in aberrant vocalizations, such as talking to himself, humming songs, and loud sighing. His mother believed that this behavior impaired her son’s awareness to the surroundings, made him “stand out” among peers, and distracted him from learning opportunities.

Target Behavior

The behavior targeted for this study was Toby’s aberrant vocalizations during independent reading time. Operationally, the behavior was defined as each word, phrase, or noise produced voluntarily. Involuntary sounds such as coughing and sneezing, and words in conversation with his mother were not counted. All repetitions of a specific vocalization were tallied individually during data collection. The time when Toby returned home from summer school was selected for data collection. This was the time his vocalizations became the worst and concerned his mother the most.

Implementation Procedures

A social story entitled “Reading Books” was created to describe how others would usually do during reading time and discuss the importance of being quiet. An English translation of the original Chinese social story may be viewed in Appendix A. Original music was composed to accompany the words of the story. The printed music may be found in Appendix B. Toby was assigned to the treatment order ACAB. Data collection lasted thirty minutes, from 5:00-5:30 p.m. A digital video camera was placed at the apartment to view Toby’s “reading corner” across this period of time. During treatment conditions, the researcher met Toby immediately before the data collection period. During condition B, the researcher read the social story to Toby as he followed along by reading the story and following the words with his finger. During

29 condition C, the researcher sang the story to Toby with guitar accompaniment. Toby would either listen quietly or attempt to sing along with the researcher. After meeting with the researcher, Toby started reading books of his choice and the researcher left the apartment. Reliability data were collected by having an independent observer viewed 25% of the digital tapes. Mean inter-observer reliability across all four conditions was 91.20%.

Results of Case Study II

Visual inspection of the data in Figure 2 reveals a high number of aberrant vocalizations during the initial baseline, followed by a pronounced decline after the implementation of the first treatment condition, singing the story. Occurrences of target behavior increased during the second baseline as compared to the previous treatment condition, but still did not achieve the levels seen in the first baseline. During the last treatment condition, fewer occurrences of the target behaviors were again noted. A t-test comparing the first baseline condition to the music condition (Research Question Two) yielded a significant difference (p = .04) (See Table 3). A comparison between the second baseline condition and the reading condition (Research Question One) a significant difference was also found (p = .01) (See Table 3).However, the final comparison between the two treatment condition was statistically insignificant (p = .17) (See Table 3).

Follow-up

The researcher contacted Toby’s mother approximately three weeks after termination of the experiment. She said although it was not observed that Toby read or sang the story, and verbal cues to stop the target behavior were seldom given, the frequency of his aberrant vocalizations remained low. She was pleased with the results and thought that Toby’s participation in the study was beneficial.

30 160 Baseline 1 (A) Story Sung (C) Baseline 2 (A) Story Read (B) 140

120

100

Aberrant Vocalization 40

0 1 2 3 4 5 6 7 8 9 10 1112131415 1617181920 Observation Days

Figure 2. Frequency of aberrant vocalizations exhibited by participant Toby by condition.

Table 3 t-tests for condition comparisons for participant Toby Comparison t df p A1:B 3.11 4 .04 A2:C 5.48 4 .01 B:C 1.70 4 .17

Case Study III

Background

Cindy was an eight-year old female. She was diagnosed with Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS) at age one. The diagnosis changed to autism when she was three. She was a second grader at a primary school for children with special needs. Cindy’s reading ability was well below grade level. Cindy received early intervention from age two to four in which she had individual physical therapy sessions, individual and group occupational therapy sessions once a week. She then attended a preschool for children with special needs for two years. In additional to the two therapies she had been receiving in early intervention, individual speech therapy service was provided to Cindy in this period of time. Moreover, she received individual music therapy weekly for six months and group music therapy once a week for a year from a private music therapist to improve her social skills and direction following. These music therapy services, though, did not specifically address the target behavior identified for the present study. Cindy’s mother noted that her daughter reacted positively to music. She liked to sing and often use singing as a way of emotional expression. Parents and teachers at school would also use music to calm Cindy down. Although Cindy did not have a strong rhythmic sense, she had a good melodic memory. She was able hum the piano piece played by her older brother. Cindy displayed many typical characteristics of autism such as delayed in the developmental of spoken language, echolalia, short attention span, and underdeveloped peer relationships. She had a desire in social play; however, her lack of social skills hindered her from appropriately initiating or sustaining an interaction with others. For example, Cindy often hit, shouted right at her brother’s ear, or exhibited other aggressive behaviors when she wanted to play with him. She did not realize her brother’s feelings upon her behaviors. She had demonstrated such inappropriate ways of initiating interaction for more than four years. Previous interventions to remediate these undesirable behaviors had been unsuccessful. These behaviors irritated Cindy’s brother at home and he dubbed these behaviors “attacks.”

Target Behavior

The behavior targeted for this study was Cindy’s aggressive behaviors toward her brother. Operationally, the behavior was defined as every time Cindy “attacked” or attempted to attack her brother. “Attacks” included hitting, pinching, kicking, pulling hair, shouting right at ear, and putting saliva or scotch tape on brother’s face or arm. Each occurrence of the target behavior was tallied. The time Cindy’s mother prepared dinner was used for data collection. This is the period during which Cindy and her brother were together at home and the target behavior was most prominent.

32 Implementation Procedures

A social story entitled “How to play with Brother” was created for Cindy that focused on appropriate ways of initiating a play with her brother. The story also noted the feelings of her brother upon her aggressive behaviors. An English translation of the original Chinese social story may be viewed in Appendix A. Original music was composed using the text of the social story as lyrics. The printed music may be found in Appendix B. Cindy was assigned to the treatment order ABAC. Data collection lasted thirty minutes, from 7:00-7:30 p.m., before the family’s dinnertime. A digital video camera was placed at a corner in the apartment with wide- angle lens to view the entire living room area where Cindy and her brother would stay during this segment of time. During treatment conditions, the researcher met Cindy immediately before the data collection period. Though her reading ability was well below grade level, Cindy would occasionally read or sing the story along with the author by imitating the sounds. However, she was unable to turn pages at appropriate times and required the researcher’s prompts and assistance. The researcher left the apartment after reading or singing the story once and data collection began. Reliability data were collected by having an independent observer viewed 25% of the digital tapes. Mean inter-observer reliability across all four conditions was 86.83%.

Results of Case Study III

Figure 3 depicts a visual representation of the data collected. It shows that data under each condition are highly erratic. Nevertheless, the lowest instances of the target behavior were achieved during the music condition. A t-test comparing the first baseline condition to the reading condition (Research Question One) yielded no significant difference (p = .96) (See Table 4). When comparing the second baseline condition to the music condition (Research Question Two), no significant difference was found (p = .34) (See Table 4).The final comparison between the two treatment conditions again produced no significant results (p = .97) (See Table 4).

Follow-up

Approximately three weeks after the final treatment day, the researcher contacted Cindy’s mother. She said that the occurrence of the target behavior had decreased when compared to the time of the experiment. She believed that it might be the new intervention the family used with Cindy to reduce her aggressive behaviors toward brother, although Cindy’s brother would sing the story to her sometimes. However, it was not observed that Cindy had read or sung the story herself, and her mother did not think the music therapy intervention was effective.

33 30 Baseline 1 (A) Story Read (B) Baseline 2 (A) Story Sung (C)

25 s

10 Aggressive Behaviour Aggressive

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2 0 Observation Days

Figure 3. Frequency of aggressive behaviors exhibited by participant Cindy by condition.

Table 4 t-tests for condition comparisons for participant Cindy Comparison t df p A1:B - .05 3 .96 A2:C 1.08 4 .34 B:C .04 3 .97

34 Case Study IV

Background

Karen was a twelve-year-old female who received a diagnosis of autism at the age of two. She had an older brother who also had autism. According to her mother, Karen’s learning abilities and intelligence were as competent as her normal counterparts. She attended a typical primary school; however, the teachers did not expect the same from Karen and from other students. Karen’s reading level was at grade level. After being diagnosed with autism, Karen attended a preschool for children with special needs for three years prior to entering primary school at age of six. She received occupational therapy once a week for two years at the preschool, but had never received speech therapy, physical therapy and music therapy services. According to Karen’s mother, her daughter enjoyed music. She liked to sing, especially tunes from TV. She also had a good rhythmic sense. Karen just started individual piano lessons at the time of the present study. Her mother noted that Karen had a great interest in playing the piano and would use it as a means to relax. Karen displayed some characteristics associated with autism including undeveloped peer relationships, and marked impairment in initiating a conversation or an interaction. She was keen to make social contacts with others; however, she possessed few of the skills necessary for doing so. One of the greatest concerns for her mother was how to stop Karen from putting uneatable things in mouth. She often put her fingers or other objects in her mouth when she felt bored or anxious. Such behavior was a serious hygienic problem and it always upset her stomach. Karen’s homework time was selected for data collection as that was the time the behavior got worst, especially when she struggled with a question.

Target Behavior

The behavior targeted for this study was decreasing the behavior of putting things in mouth during homework time. Operationally, the behavior was defined as every time Karen put her fingers, pencil, eraser, or any other uneatable objects in her mouth. The duration of target behavior was recorded. Karen’s homework time was scheduled for data collection.

Implementation Procedures

Following the identification of the target behavior, a social story entitled “When I was thinking….” was created to describe how people would usually do when they think and discuss the consequences of putting uneatable things in mouth. An English translation of the original Chinese social story may be viewed in Appendix A. Original music was composed to accompany the words of the story. The printed music may be found in Appendix B. Karen was assigned to the treatment order ACAB.

35 Data collection lasted an hour, from 3:30-4:30 p.m. A digital video camera was placed at the apartment to view the desk where Karen did her homework in this segment of time. During treatment conditions, the researcher met Karen immediately before the data collection period. During condition B, Karen would listen quietly as the researcher read the social story to her. During condition C, the researcher sang the story to Karen with live guitar accompaniment. She would either listen closely or sing along with the researcher. After meeting with the researcher, Karen started to do her homework from summer school. The researcher then left the apartment and data collection period began. Reliability data were collected by having an independent observer viewed 25% of the digital tapes. Mean inter-observer reliability across all four conditions was 88.43%.

Results of Case Study IV

Visual analysis of the data collected is shown in Figure 4. It indicates high occurrences of putting things in mouth during the first baseline condition and an overall downward trend, except on the first day of the music condition, in the duration of the target behavior following the first treatment condition. The subsequent return to baseline did not achieve the levels seen in the first baseline. During the last treatment condition, reading the story, the duration of target behavior was even lower. A t-test comparing the first baseline condition to the music condition (Research Question Two) yielded no significant difference (p = .78) (See Table 5). A comparison between the second baseline condition and the reading condition (Research Question One) was not significantly different (p = .06), although the value approached significance (See Table 5).The final comparison between the two treatment conditions produced no significant results (p = .08) (See Table 5).

Follow-up

Approximately three weeks after termination of the experiment, the researcher contacted Karen’s mother. She confirmed that the occurrence of the target behavior remained low. Karen was often able to remind herself right after putting uneatable things in mouth. Sometimes, her mother would sing the first phase of the song to Karen when Karen tended to put things in mouth. Karen would immediately recall what the song was about and what behaviors were expected from her. Karen’s mother was pleased with the results and thought her daughter’s participation in the study was beneficial.

36 140

Baseline 1 (A) Story Sung (C) Baseline 2 (A) Story Read (B)

120

100

40 Putting Things in Mouth Putting Things

0 12345 67891011121314151617181920 Observation Days

Figure 4. Duration of putting things in mouth (in seconds) exhibited by participant Karen by condition.

Table 5 t-tests for condition comparisons for participant Karen Comparison t df p A1:B .29 4 .78 A2:C 2.69 4 .06 B:C 2.32 4 .08

37 CHAPTER 5

DISCUSSION

The purpose of the present study was to investigate the effect of social stories and their musically adapted versions on modifying behaviors of children with autism in home-based environments within a Chinese culture. Social stories are an increasingly popular tool for teaching social skills to children with autism by providing them with accurate social information. Previous research regarding the heightened interest in music exhibited by persons with autism (Blackstock, 1978; Kolko et al., 1980; Thaut, 1987) and empirical studies supporting the use of musical versions of social stories (Brownell, 2002; Pasiali, 2004) provide the rationalization for exploring the use of this technique within a different culture. Evaluation of the results indicated that target behaviors improved significantly after the implementation of the first treatment, using either the reading or singing form of social story, for two out of the four participants (Mike, Toby). Significant differences between the second baseline and the second treatment conditions were again found for the same two participants, and significance was approached for a third participant (Karen). Data under each condition for all participants were erratic, especially in Cindy’s case. This erraticism may be attributed to participants’ family members, their family schedules, and to the volatile nature of the participants themselves. For example, on the second day of the first baseline condition, Toby wanted to play computer games and spent little time reading books during the data collection period; thus, these circumstances resulted in a relatively low frequency of aberrant vocalizations that day when compared to other days in the week. Also, on several days of data collection, Toby’s mother verbally reminded him to keep quiet. Her behavior obviously influenced the possibility of getting reliable data regarding the treatment efficacy. In Cindy’s case, the proximity of her brother during data collection period varied greatly across the four conditions, which directly affected the number of times Cindy would exhibit aggressive behaviors toward him. Failure to observe complete reversal during the second baseline condition may imply that learning effects took place after the initial implementation of treatment. Follow-ups conversations with the parents three weeks after termination of the experiment support this assumption. Further evidence of accumulative learning effects is that positive changes occurred most often in the last phase of experiment, whether the condition was reading the story or singing the story. It is noteworthy that although two of the four participants were able to make improvements on the first day of the music condition (Mike and Toby), they were all distracted by the guitar the researcher played. The children were curious about the instrument and spent most of the time looking at the guitar when the researcher was singing. Their behavior may have been due to the novelty of this instrument in the Chinese culture, especially among children. In spite of their curiosity, the children started

38 to pay attention to the social story song and make more progress from the second day of the music condition. In conclusion, either form of the social story, spoken or sung, was successful in bringing positive behavioral changes in three of the four participants (Mike, Toby, and Karen). It is likely that positive results were not obtained with Cindy because of her impaired receptive language ability. Additionally, her extremely short attention span may have precluded her from fully grasping the meaning of social story. Although the generalization of positive behaviors was not the focus of this study, two participants (Mike and Karen) generalized their behavioral changes to other environments not targeted in the program. According to Mike’s mother, her son displayed more proper sitting behaviors in vehicles and restaurants than before his participation in this research. In addition, Karen was found to engage less in her negative target behavior in situations other than homework time. There are clearly some factors that may limit generalization of the study’s finding to other children with autism. First, it was difficult to recruit participants. This difficulty was mainly because many parents approached by the researcher were not able to pinpoint a problematic behavior of their children suitable for the purpose of this study. The second limitation was imposed by the experimental design. As the duration of each intervention was chosen for convenience, stability within and across conditions was not obtained. Such an absence of stability may limit the generalization of the findings. A final limitation relates to the technique being examined in the present study. Writing and implementing a musically adapted social story requires a certain level of musical training. This musical requirement may limit the feasibility of using such an intervention by parents who are not trained in or comfortable with music. As suggested by Brownell (2002), the technique of “Piggybacking,” a process of altering the lyrics of a familiar tune to desired information, may be of assistance. Parents may also seek help from somebody to write and make recording of social story songs which can be used with a target child. There is no question that more research is necessary to further investigate the validity of using musically adapted social stories with children who have autism. Research using group comparison designs may produce more generalizeable results. However, the extreme idiosyncrasies among individuals with autism would make creating large experimental groups with homogeneous characteristics difficult, if not impossible. Future researchers may also explore the use of colored story books versus black and white story books. The parent of one participant in this study reflected that her child was not interested in the black and white story book the researcher made, as the child always read books with color and would find a black and white one unattractive and boring. Although it was suggested by Gray and Garand (1993) that using a black and white story book would reduce distraction, it is possible that some individuals with autism may not attend to a book that is unattractive to them. If this is the case, the black and white visually-based rationale for social stories may be unwarranted. Another extension of the present research may involve the piggybacking technique. However, as the intonation of the Chinese language is very complicated, it may be more difficult for practitioners to piggyback a Chinese social story to a familiar tune than to compose original music. This research study does not provide a universally effective technique with Chinese children who have autism. Nevertheless, based on the preliminary findings on this

39 somewhat novel technique of presenting social story information, it appears that a musical presentation of social stories may be an alternative for practitioners to teach social skills to children with autism who have an affinity for music.

APPENDIX A

41 English Translations of the Original Chinese Social Stories

Social Story for Mike: “Watching TV”

Sometimes I watch TV at home.

Mommy usually sits on the sofa and watches TV with me.

If I fidget and run around, mommy and I may not be able to watch TV.

Mommy will be unhappy if I disturb her from watching TV.

Mommy will worry me if I run around and hurt myself.

I will try to sit still when watching TV.

Social Story for Toby: “Reading Books”

Sometimes I like to read at home.

People usually don’t talk when they read.

People talk when they want to ask questions.

If I talk during reading time, mommy may think I have questions.

If I talk during reading time, mommy will be unhappy.

If I talk during reading time, I can’t concentrate on the books.

I will try to read quietly.

42 Social Story for Cindy: “How to Play with Brother”

Sometimes I want to play with brother.

I may play toy trains, watch TV, or go to the playground with brother.

I may also tell brother what I want to play.

But if I hit brother, he will get hurt; he will not want to play with me anymore.

If I put saliva on brother’s face, he will be unhappy; he will not want to play with

me anymore.

I will try to treat brother right, not to hit him and put saliva on his face.

Social Story for Karen: “When I Am Thinking....”

I need to do homework almost every day.

Sometimes, I do Chinese homework.

Sometimes, I do English homework or works for other subjects.

I may also do some drawings.

When encountering difficulties in the questions, or trying to get inspiration for

drawings, I may need some time to think.

People usually put their hands on the desk or under chin when they think.

If I put my hands, pencil, or other uneatable things into mouth when I’m thinking,

germs will jump into my stomach.

I may get a stomachache.

Mommy will worry me if I’m sick with stomachache.

I will try to put hands on desk or under chin when I’m thinking.

APPENDIX B

44 Original Music for the Social Stories

APPENDIX C

49 Social Story Books

Story Book for Mike

53 Story Book for Toby

58 Story Book for Cindy

63 Story Book for Karen

APPENDIX D

69 Human Subjects Committee Approval Letter

APPENDIX E

71 PARENTAL CONSENT FORM

I freely and voluntarily and without element of force or coercion, allow my child to be a participant in the research project entitled “Modifying Behaviors of Children with Autism: The Use of Musically Adapted Social Stories in Home-Based Environments.”

This research is being conducted by Yuen-man Chan, who is a Graduate Student at Florida State University. I understand the purpose of her research project is to determine if a musical presentation of social story information can decrease undesirable behaviors in children with autism. I understand that if my child participates in the project, a social story will be written for my child by the researcher to modify a problematic behavior of my child. Subsequently, the researcher will read or sing the social story to my child in two intervention phases in the study.

I understand that the total time commitment would be about 60 minutes each day, five days a week for 4 consecutive weeks. If I participate in the project, the researcher will discuss the results of my child’s case with me at the end of the project. My questions will be answered by the researcher or she will refer me to a knowledgeable source.

I understand my participation is totally voluntary and I may stop participation at anytime. All data collected on my child will be kept confidential, to the extent allowed by law, and identified by a false name. My child’s name will not appear on any of the results. Individual responses will be reported as a case study. All data will be kept by the researcher during project period in a locked filing cabinet to which only the researcher will have access and will be destroyed by August 8, 2010.

I understand there is a possibility of a minimal level of risk involved if I agree to allow my child to participate in this study. My child might experience boredom when not finding the story interesting. I am also able to stop my child’s participation at any time I wish.

I understand there are benefits for participating in this research project. First, my child will receive these services free of charge. Also, my child may improve social skills by decreasing an undesirable behavior. I will be providing valuable information on social skill acquisition by children with autism. This knowledge can assist therapists and educators in providing future services that help children with autism remediate their social skills.

I understand that my child will be videotaped by the researcher to ensure accurate data collection. These tapes will be kept by the researcher in a locked filing cabinet. I understand that only the researcher will have access to these tapes and that they will be destroyed by August 8, 2010.

I understand that this consent may be withdrawn at any time without prejudice, penalty or loss of benefits to which I am otherwise entitled. I have been given the right to ask and have answered any inquiry concerning the study. Questions, if any, have been answered to my satisfaction.

I understand that I may contact Yuen-man Chan (HK: 6101-4026/ 26726393; USA: 1-850-591-2408) or the Human Subjects Committee at Florida State University (USA: 1-850-644-7900) for answers to questions about this research or my rights. Individual results of my child will be sent to me upon my request.

I have read and understand this consent form.

______Child’s Name Parent’s Name

______Date Parent’s Signature

APPENDIX F

73 CHILD ASSENT

Hello, ______, my name is Yuen-man. How are you doing today? I would like your help in a study that I am conducting. I’m going to read you a story (or sing you a song) for five days. All I want you to do is pay attention to me when I read (or sing).

I’m going to read a story (or sing a song) to some other children whom you may not know too. If you don’t want to listen to the story (or the song) anymore when I haven’t finished it, you just let me know and we can stop at anytime. You won’t get in any trouble, and no one will be mad at you. Okay? So will you help me by listening to the story (or the song)?

If Yes – Great. But before I’m going to read you a story (or sing you a song with my guitar accompaniment), do you see the black box over there? That is a video camera. It will be recording for 30 minutes (or an hour), and that will help me remember what you do which is very important. I’m going to leave it right over there so we don’t touch it and keep it safe. Okay, we are all set. Are you ready to begin?

If No - If the child says “no”, the child will be free to leave, thanked by the researcher, and dismissed from the study.

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84 BIOGRAPHICAL SKETCH

Yuen-man Chan, as known as Ivory, was born and reared in Hong Kong, China. She attended the Chinese University of Hong Kong from 2000-2003 where she received her Bachelor of Arts degree, majoring in Music and minoring in Psychology. She began her Master’s Degree in Music Therapy at Florida State University in Fall 2003 with a full grant from the Hong Kong Jockey Club Music and Dance Fund. Her outstanding scholarship and musicianship has been recognized by the national music honorary society Pi Kappa Lambda. Upon completion of the Master’s degree, Ivory will return to Hong Kong and join the music therapy profession in the territory.