Running head: SYSTEMATIC REVIEW

Increasing Social Participation for Children with Autism Spectrum Disorder through Media-Based Social Stories: A Systematic Review Charmaine Loja and Chrys Quiroz Touro University Nevada

SYSTEMATIC REVIEW Objectives Focused Clinical Question

Does media-based Social Stories increase social participation for children with Autism Spectrum Disorder (ASD)? Purpose There has been an extensive amount of research that supports Social Stories through a book-format. However, there is currently a lack of research involving media-based Social Stories and their influence on increasing social participation for children with ASD. Examples of media-based Social Stories include video modeling, PowerPoint, iPad presented, and musically adapted media. The purpose of this systematic review (SR) is to explore the various avenues of media-based Social Stories and determine the effectiveness of their outcomes. Question Relative to the Topic Initially, the overall topic involved adolescence with ASD and social skills training. Due to the broad scope of the topic, the researchers found it necessary to focus efforts on a specific type of social skills intervention, thus concentrating on media-based Social Stories. Furthermore, there was a lack of research that examined social skills treatment specifically to adolescence. Therefore, the researchers determined that increasing the age range to include children would expand the selection of articles to review. Importance of the Question Relative to Overall Topic The focused topic is significant to the overarching issue because it provides additional options for interventions to treat social impairments. Considering that media-based Social Stories present as a relatively novel intervention strategy, it is important to increase exposure of the topic to clinicians that may be struggling with additional treatment methods. As the use of

SYSTEMATIC REVIEW technology is becoming more prominent as a modality for treatment, the topic of media-based Social Stories intrigued the researchers which resulted in the formulation of the overall research question. Introducing supplementary and specific methods addressing social participation exposes clinicians to treatments that can alleviate social deficits. This can broaden the selection for

available treatment options and increases the number of interventions that a clinician can choose from. By having alternative methods, it promotes individualized treatment and increases the likelihood of finding the most effective intervention for a client diagnosed with ASD. Statement of Problem The Problem Addressed by the Focused Question The focused question Does media-based Social Stories increase social participation for children with Autism Spectrum Disorder (ASD)? addresses impaired social skills for children with ASD. Three of the main characteristics for autism are difficulty in social interaction and communication, and disturbances in behaviors (Rogers, 2010). All of these behaviors and characteristics impact the ability of social participation. Through the use of multimedia Social Stories, children with ASD can learn appropriate social skills and apply them within their natural setting, thus enhancing social participation. Significance in Addressing Social Skills for Children with ASD Clinical and community-based practice of occupational therapy. According to the American Occupational Therapy Association (2008), social participation is within the scope of occupational therapy (OT). Through evidence-based interventions, OTs can provide optimal treatments for children with ASD that can significantly improve their social interaction with their

SYSTEMATIC REVIEW peers, decrease inappropriate behaviors, facilitate play with others, and improve positive social behaviors. The education and training of occupational therapy students. Through research, various methods for social participation, including multimedia Social Stories, can have strong evidence-based support. When there is a sufficient amount of evidence-based support for multimedia Social Stories and their effectiveness, it can then be incorporated into the curriculum of OT programs. This can contribute to the overall education and training for OT students, and broaden the topic for interventions related to the area of social participation. Refinement, revision, or advancement of knowledge, theory, or research. By expanding on the medium in which Social Stories can be presented, particularly through multimedia, it can advance the development of Social Stories, providing more options that would be most effective for a child with ASD. Program development. During the development of an OT program, protocols and

procedures need to be established to assure consistency and quality of services. When addressing social impairments for children with ASD, multimedia Social Stories can be added onto the list of protocols and procedures for the program. Societal needs. Society has a general set of social norms and rules that everyone is expected to follow, such as maintaining eye contact. However, for children with ASD, following the social norms may be difficult. Addressing social impairments for children with ASD can contribute to the ongoing research dedicated to finding effective methods for alleviating the social impairments. This can allow children with ASD to function in a more acceptable manner within society.

SYSTEMATIC REVIEW Health care delivery and health policy. Health care delivery and health policy emphasize the importance of having an interdisciplinary team (IDT). When treating children with ASD, team members of their IDT can include doctors, nurses, psychologists, physical

therapists, occupational therapists, and speech language therapists. By increasing evidence-based support for the use of multimedia Social Stories, health care delivery can be strengthened by allowing occupational therapists to discuss with the other team members and advocate to include this approach as part of the childs treatment plan. Coverage of payment for occupational therapy services at local, state, and national levels. According to Autism Health Insurance Project (2013), coverage of treatment depends on the amount of medical literature that supports the effectiveness of treatment. Due to the lack of research that focuses on multimedia Social Stories, coverage of payment at local, state, and national levels may be limited. By conducting research, it can be more accepted as treatment for social impairments within the medical field, thus increasing coverage of payment. Background Literature Background Information According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), the diagnostic criteria for ASD are persistent deficits in social communication and social interaction across multiple contexts [and] restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric Association [APA], 2013, para. 4). Diagnoses that fall under the umbrella term of Autism Spectrum Disorders include autism, Asperger syndrome, Rett syndrome, Childhood disintegrative disorder, and Pervasive Developmental Disorder- Not Otherwise Specified (APA, 2013). An additional major known characteristic related to ASD involve social deficits. Wing (1988) indicated components of social interaction include: (a) social recognition,

SYSTEMATIC REVIEW which involve interest in others, (b) social communication, expressing ones self and understanding body language, and (c) social imitation and understanding, which involve understanding others feelings and ability to engage in imaginative play (as cited in Ozdemir, Universitesi, Fakultesi, & Bolumu, 2008). Current Research Existing research suggest providing multiple strategies to teach Social Stories to increase effectiveness (Brownell, 2002; Spence, 2003). Combining social skills training through the medium of visually cued instruction has been researched to help children with autism learn social skills (Litras, Moore, & Anderson, 2010). Other input mechanisms such as an auditory strategy through music have also been studied (Brownell, 2002). Thaut (1992) formed the

musically adapted technique upon the basis that children with autism respond positively to music therapy interventions (as cited in Brownell, 2002). It is important to focus on social impairments in children with ASD because of its profound detrimental effects to development if left untreated. If social interaction and functional communication are not addressed within an individuals repertoire, it can affect multiple facets of their life such as properly accessing education and engaging as a member of a community (Ozdemir et al., 2008). Autism can be deemed as a highly perplexing diagnosis considering that it presents differently in each individual. It is expected that intervention strategies be individualized and contingent upon each client. This characteristic leads to difficulties in generalizability of studies conducted regarding the efficacy of Social Stories. As a result, clinicians may remain hesitant and struggle with current interventions. Social Stories were originally developed by Carol Gray in 1991 (The Gray Center, n.d.a.). The Social Stories are based on the foundation that they are individualized for each students abilities and interests, and created to fit a given

SYSTEMATIC REVIEW situation (Brownell, 2002, p. 120). Grays introduction and development of Social Stories remains one of the primary supported interventions to remediate social deficits. In addition, Social Stories are appropriate for children with trainable mental impairment, basic language skills, high-functioning autism or Asperger syndrome, and lower functioning students with autism (Brownell, 2002, p. 120). Digital media is viewed as a novel, but engaging, strategy to teach social skills. Visual supports have been found to be enjoyable to children. Being able to recognize familiar people advances learning and enhances social skills. Benefits of utilizing digital media include control of ones learning experience, direct feedback, and phonemic awareness (More, 2008). In addition, increased motivation, engagement and positive attitude, and attention to task were noted (More, 2008). Relevant Definitions of Intervention and Approach

Acquiring social skills can be taught in various modes of media through Social Stories. These include PowerPoint, iPad, computer, videotapes, video self-modeling (VSM), and music. Social Stories are unique in their relatively short length, personalization, and being written from the perspective of the student (More, 2008, 169). There are specific types of sentences utilized such as descriptive, perspective, affirmative, and directive sentences. These sentences are specific to and change depending on the childs needs. Contribution to Resolution This SR will contribute to the current body of evidence by providing a recent account of studies that involve Social Stories through media-based avenues. Researchers were prompted to focus on the aspect of media-based Social Stories due to the lack of research regarding this particular concept. As a result, this SR will contribute to the overall knowledge of Social

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Stories and the use of media-based mediums. In addition, the researchers utilized an extensive search and have critically appraised each article found. This compilation of results will save time and effort of clinicians by offering an overall synthesis and implications for practice. Methods Search Strategy The researchers used multiple avenues to find appropriate articles for the SR. Resources that were used included online databases and recommendations from peers and professor. Both researchers conducted the search for the studies. Inclusion and Exclusion Criteria Originally, inclusion criteria were comprised of: publication dates from 2006 to 2013, full-text availability, peer-reviewed publication, autism, Asperger syndrome, children, participants ages 3- to 13-years-old, written in English only, any ethnicity for participants, Social Stories, and studies conducted in the United States. However, due to the minimal amount of studies, modifications to the inclusion criteria were required. The modified inclusion criteria were comprised of: publication dates from 1999 to 2013, autism, Asperger syndrome, Social Stories, participants ages 3- to 12-years-old, and children. Exclusion criteria were comprised of: use of Social Stories that were not facilitated through a multimedia approach, adult participants, systematic reviews, outcomes that did not involve social skills, and publication dates earlier than 1999. Procedures for Article Identification and Collection Researchers predominantly used the internet to find articles for the SR. Studies identified for the SR were found through a variety of search engines and databases, including Google

SYSTEMATIC REVIEW Scholar, EBSCOhost, and PubMed. Once articles were identified, they were saved in the EndNote program as a tool to track citations for potential use in the SR. Screening Procedures After an extensive search, 25 articles were initially found that fulfilled the inclusion criteria. To determine if the articles were appropriate for the SR, the researchers evaluated the

studies based on level of evidence, study design, and sample size by briefly scanning the content (see Appendix A for a copy of the Levels of Evidence chart). A total of 13 articles that were either systematic reviews or literature reviews that did not fit the inclusion criteria were excluded from the researchers collection of studies. After screening the articles, the researchers critically appraised each article using the McMaster University Critical Review Form- Quantitative Studies (Law et al., 1998). To determine the quality for each article, a peer review process entailed meeting once a week, for 10 weeks, to discuss the strengths and weaknesses. As a result, it was concluded that 12 of the 25 articles were the strongest in addressing the topic, thus were chosen to be used for the SR. Researchers then compiled all 12 studies into the American Occupational Therapy Association (AOTA) Evidence Table to record essential components of each study such as the objective, participants, study design, level of evidence, intervention, outcome measures, results, and limitations (AOTA EBP Project, 2013). Results Evidence Table See Appendix B for a copy of the AOTA Evidence Table. Narrative Synthesis Computer program. Social Stories presented through a computer program called HyperCard Software can be used to influence social skills for children with ASD (Hagiwara &

SYSTEMATIC REVIEW Miles, 1999; Ozdemir et al., 2008). Articles that utilized HyperCard Software to create and present Social Stories showed effectiveness, depending on the desired outcomes for each article. Hagiwara and Miles (1999) investigated the use of Social Stories and their

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effectiveness on improving target behaviors for children with ASD. The authors used a Level III multiple baseline design. The participants were children with ASD between the ages of 7- to 9years-old who were recruited from a suburban elementary school. All children were enrolled in inclusionary settings for either part or most of the day. Target behavior for two participants was washing hands, while target behavior for the third participant was on-task behavior. Based on their target behavior, each participant was instructed to read his or her personalized Social Story on the computer before entering their designated setting. Social Stories were created through the HyperCard software and presented via computer. Data collection occurred during baseline and intervention phases. However, intervention implementation occurred in a staggered fashion, in which stability and level trend needed to occur in the first setting before the intervention was implemented in the second setting. The same process occurred for the third setting. Outcomes were measured through observation, anecdotal records, and line graphs. The results showed that 2 of the 3 participants demonstrated improvement in their target behavior. Participant 1, whose target behavior was washing hands, exhibited his target behavior with 100% accuracy in completion on the last of intervention in the before-morning and before-lunch settings. Additionally, the data indicated generalization of skills in after-recess setting. Participant 2, whose target behavior was also washing hands, showed improvements during before-lunch and after-recess settings. His performance improved by 93% completion, in which he required prompting to complete his task. Participant 3, whose target behavior was on-task

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behavior, showed inconsistent improvement during the average duration of on-task behavior. He did demonstrate some improvement in the lunch and resource room settings, but intervention implementation could not occur in the general education classroom due to changes in the program. Limitations include limited duration of the intervention, lack of consistency in which the interventions occurred, and the presence of attention bias, in which the teachers and paraprofessionals knew the purpose of the study. Ozdemir et al. (2008) examined the effectiveness of Social Stories presented via computer on the duration of appropriate social engagement. The authors used a Level III beforeand-after design. The participants were three children with ASD who were between the ages of 5- to 6-years-old. Each participant was paired with two typically developing peer, one boy and one girl, either during intervention sessions or during play sessions for generalization probes. Data collection occurred during baseline, intervention, two maintenance probes, and generalization phases. Social Stories were created through the use of the HyperCard software and were presented via computer. Intervention implementation occurred three times a week, in which the participants were instructed to watch the Social Story that described that particular days activity. Activities can include art, pretend play, games, and building activities. Then, the participant and his partner were instructed to play in the play area for 10 minutes. Intervention occurred in a staggered fashion, in which only the first participant received the intervention while the other participants remained in baseline until the first participant met Criterion 1. This is when the data showed an increase in level, an accelerated slop, increase in median data, and no overlap with baseline data. When the first participant met Criterion 1, the second participant received the intervention. The third participant received the intervention when the second participant met Criterion 1. Outcomes were measured through observation, social engagement

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codes, and line graphs. Overall, results showed an increase in the duration of appropriate social engagement for all participants. They all demonstrated longer time spent socially engaged with peers. However, only two participants showed generalization. Limitations include lack of conformity to the recommended guidelines, weak and flawed research design, and the presence of cointervention bias. Furthermore, lack of masked or independent evaluation was present. Multimedia format. Multimedia format combined various modes of media into one intervention, such as photographs plus auditory cueing and videotape, PowerPoint presentation plus video modeling presented via iPad, PowerPoint presentation plus video modeling, and VSM plus text cues, pictures, and paper format, respectively (Bernad-Ripoll, 2007; Kagohara et al., 2012; Sansosti & Powell-Smith, 2008; Thiemann & Goldstein, 2001). Three of the four articles listed documented effectiveness of the multimedia Social Stories, depending on the desired outcomes for each article. Kagohara et al. (2012) evaluated the effects of Social Stories and video modeling for teaching two participants how to properly greet adults. The authors used a Level III multiple-baseline design. The two participants consisted of a male and female who were classmates in the same school. Both were 10-years-old and diagnosed with Asperger syndrome and Attention Deficit Hyperactivity Disorder (ADHD). The target behavior was to independently greet a teacher or the respective research staff. This outcome was measured using levels obtained through observation. Levels were determined using the scale of none, partial, and full. A recording of partial was documented if the participant gave a simple greeting such as Hi or Hello. A recording of full was documented if the participant gave a complex greeting such as Hello, how are you? A recording of none was documented if no greeting was initiated by the participant. Data collection involved the teachers and research staff anticipating a

SYSTEMATIC REVIEW self-initiated greeting from the student upon first encounters each day. The teacher and the

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research staff would wait for five seconds for a greeting from the participant. If there was none, the teacher or research staff would initiate the greeting and wait for a reply from the participant. The two training methods were Social Stories via PowerPoint presentation and video modeling via iPad. The story described social expectations involved with greeting at school through the form of a paragraph and simple illustration. They were then asked the questions: (a) What do people do when they first see each other? and (b) What can I try to say to adults at school? The video modeling component showed two cartoon characters meeting each other and greeting at school. They were then asked (a) What can I say to someone when I first see them? During the Social Story phase, the participants were shown a PowerPoint presentation through an iPad. During the video modeling phase, the participants would be provided an iPad to independently manipulate and watch an instructional video. The teacher and research staff gathered data during both phases. The follow-up phase involved no training and only entailed the greeting procedure. Results indicate that both participants learned how to greet adults at school, but levels of success were inconsistent. Both participants conveyed greetings after the Social Story intervention and complex greetings after the video modeling intervention. However, greetings were inconsistent, suggesting that this may be due to the participants school routine. There was a decrease in greeting values on Monday, which may be a result of the lack of follow-through during the weekend, and also a lack of generalization of greeting skills acquired. Limitations include short duration of intervention as well as the morning arrival time to school of the participants and any interactions prior to school that may influence their overall disposition. Greeting opportunities also did not occur every day if the participant was absent or late to class.

SYSTEMATIC REVIEW Sansosti and Powell-Smith (2008) wanted to determine the effectiveness of computer-

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presented Social Stories and video models on social communication. The authors used a Level III multiple-baseline design. Participants were three boys with ASD between the ages of 6- to 9-years-old who were chosen from an established educational program for students with ASD in an elementary school. Target behavior for two participants was joining in, while the third participant was maintaining conversations. Based on their target behavior, each participant was given a personalized Social Story and a video that showed a demonstration of the target behavior by the participants typically developing peer. After being shown the Social Story and video via computer, the participant would be sent to his target social setting. The two participants whose target behavior was joining in were sent to a play area on the side of the school. The participant whose target behavior was maintaining conversations was sent to the same play area, but also in a nearby courtyard that contained basketball hoops. Data collection occurred during baseline, intervention, and follow-up phases, in a staggered fashion. Intervention implementation occurred for the first participant while the second participant and third participant did not. The second participant received the intervention when the data stabilization for the first participant occurred for at least three data points. The same process was applied to the third participant. Outcomes were measured through observation and Peer Comparison Data. Overall, the results showed that all participants had increased rates of social communication and demonstrated maintenance of skills during the two-week follow-up. However, improvement occurred after two participants received a modified intervention by adding teacher prompting due to reduced occurrences of their assigned target behavior. For generalization, only one participant, whose target behavior was joining in, demonstrated generalization, but only after his intervention was modified. Limitations include lack of assessment of reinforcement of the target behavior in

SYSTEMATIC REVIEW the target setting, short duration of follow-up, and small sample size. Furthermore, cointervention bias was present. Thiemann and Goldstein (2001) sought to enhance social communication using Social

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Stories, written text cues, and video feedback. The authors used a Level III multiple-baseline design. There were five participants. The participants were all male and attended the same school. Their ages ranged from 6- to 12-years-old. All participants were diagnosed with autism and had social deficits. The outcome areas included securing attention, initiating comments, initiating responses, and contingent responses. Each participant had 2 of the 3 outcome areas mentioned as their target areas for treatment. Procedure involved gathering baseline data from observing a 10-minute social activity between a participant and two typically developing peers. These social activities were based on pretend play, board games, or art/science project. Before baseline, the researchers explained the agenda and discussed rules of the activity. Data was collected dependent on the outcome area. When treatment began on an outcome area, baseline would begin for the subsequent outcome areas. Once treatment moved on to the next outcome area or social skill, maintenance data were collected for the preceding skill and baseline were collected for the subsequent skills. Each intervention session was 30 minutes, involving 10 minutes of visual stimuli, 10 minutes of social interaction, and 10 minutes of video feedback. Results indicated efficacy in using a combination of Social Stories, pictorial and written text cues, and video feedback to enhance social communication skills while interacting with typically developing peers. Limitations include short intervention duration and lack of generalizability. Bernad-Ripoll (2007) taught a participant how to understand emotions through Social Stories. Level IV single-subject design was used. There was one male participant diagnosed with Asperger syndrome who was 9-years-old and a superior range intellectual quotient. The

SYSTEMATIC REVIEW participant was known to have fits of anxiety, anger, and frustration. The target behavior was

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recognition of emotions and identification of appropriate actions associated with each emotion (p. 101). These outcomes were measured using three questions: (a) How do you feel? (b) Why did you feel like this? and (c) What should you do in that situation? The procedure involved videotaping the participant during daily routines that elicit stress and tantrums and occupations that displayed enjoyment. Baseline data was collected using the above mentioned questions after showing the participant a video displaying a negative and positive reaction. Intervention phase involved showing two Social Stories that displayed pictorials that explained emotions that he was having difficulty with. The opposite emotions were also shown. Discussions followed involving coping strategies. The generalization phase was implemented by the participants parents. For four days, the parents would review a Social Story. After this review period, if the participant displayed any of the negative behaviors, the parents would read the corresponding Social Story. Results indicated that the intervention was effective in teaching the participant to recognize emotions that he was feeling and successfully generalize them to other situations. Limitations include the limited amount of time spent on the interventions and the single-subject design. Video modeling. Video recordings utilized in the studies showed individuals demonstrating the target behavior for the participants through the context of VSM, Grays Social Story DVD, and adult demonstration, respectively (Litras, Moore, & Anderson, 2010; OConnor, 2009; Scattone, 2007). Two of the three articles listed documented effectiveness of media-based Social Stories through video modeling, depending on the desired outcomes for each article.

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Scattone (2007) examined the effects of combining Social Stories with video modeling on conversational skills. Level III before-and-after design was used. Only one participant was used for the study, who was a 9-year-old boy with Asperger syndrome. The three target behaviors were eye contact, smiling, and initiations. Three Social Stories were used and created into a booklet. The wording of each social story was shown in the video and narrated by an adult. After viewing the Social Story, a video was shown that presented two adults modeling the specific target behavior. The first Social Story focused on eye contact. The second Social Story focused on eye contact and smiling. The third Social Story focused on eye contact, smiling, and initiations. Data collection occurred during baseline, intervention, and generalization phases. However, only one baseline and one generalization probe were taken at the participants school during lunchtime, in which target behaviors were observed as he interacted with his peers. Intervention sessions occurred at the clinic, where the participant viewed the Social Story and interacted with one of five adults. In addition, he was also instructed to view the Social Story at home the night before going into the clinic for treatment. Viewing at home occurred after he answered comprehension questions regarding the Social Story with 100% accuracy. Treatment integrity was also measured by having participants mother complete a daily checklist to record whether or not her son watched the Social Story video. Treatment integrity was 95%. Generalization probe was taken directly after the last data point was collected. Outcomes were measured through observation and video recordings of the participant. Results of the intervention showed that the percentage of nonoverlapping data (PND) for eye contact and reciprocal interactions were 100%, making it highly effective. However, PND for smiling was 32%, making it unreliable. Limitations include only taking one baseline

SYSTEMATIC REVIEW and one generalization probe, using only one participant, short observation time, and lack of peers used in the study. Additionally, cointervention bias was present. Litras et al. (2010) investigated the effectiveness of using a multimodal approach of text-format Social Stories with VSM to teach social skills. Level IV single-subject, multiple-baseline design was used. There was one male participant with autism who was 3-years-old. Target behaviors included greeting, making invitations to play, and contingent responses. Data was collected at baseline, intervention, and follow-up. The interventions

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involved three different Social Stories through self-modeled videos that addressed each of the three target behaviors. The participant would watch the videos in the morning, mid-day, and early evening. The results showed an increase from baseline for all three targeted behavior, and generalization. It was also observed that there was a fast skill acquisition with shown improvements after the first session. The limitation of this study includes using only one participant. OConnor (2009) examined the use of Social Story DVDs to address the issue of anxiety associated with turn-taking. The authors used a Level IV case study design. There was one male participant with autism and a learning disability. His age was not stated. The targeted outcome involves a decrease with the intensity of negative behaviors such as aggression, verbal abuse, and self-injurious behaviors. Over a three week period, baseline and intervention data were collected. The intervention involved showing the Social Story DVD and participating in a turn-taking game 15 minutes prior to the participants physical education class and swimming class. It was identified that these two classes were particularly difficult for the participant to engage in normative behavior. There were also visual reminders that were utilized whenever an unfamiliar situation arose and the client needed further clarifications. Results showed that the

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overall levels of intensity decreased during swimming, but did not decrease during the physical education class. It was also deemed that generalization was not evident with the participant. OConnor (2009) discusses the likelihood of the unsuccessful outcome being attributed to the lack of personalization relative to the Social Stories DVD. There were no limitations discussed within the study. However, it is evident that there is selection bias as the author was the teaching assistant and behavioral support to the participant. Musically adapted Social Stories. Brownell (2002) investigated the effects of Social Stories through musical presentation to modify the behaviors of children with autism. The author used a Level IV ABAC/ACAB counterbalanced multiple-treatment design. Participants were four children with ASD, who were all males and between the ages of 6- and 9-years-old. All participants were verbal, had some pre-reading skills, and an affinity for music. The targeted behaviors were different for each child, which included using a quiet voice, following directions, and speaking during appropriate times. Data was collected at baseline and after each intervention. The intervention involved either reading or singing the Social Story that revolved around the targeted behavior. Once the condition was complete, the participant would return to the self-contained classroom and observation would commence. Results were discussed using statistical significance. All participants showed desirable outcomes from baseline to intervention. There was an overall improvement with a decrease in the negative behavior being more evident when the intervention was sung rather than read. Limitations discussed in the intervention involve the short duration time, lack of generalizability, and difficulty in replicating the study. PowerPoint-presented. Mancil and Whitby (2009) compared the effects of paper-assisted and computer-assisted Social Stories on decreasing occurrences of pushing classmates. Level IV ABABCBC multicomponent design was used. Participants were three

SYSTEMATIC REVIEW children with ASD, who were between the ages of 6- to 9-years-old and were either in kindergarten or first grade. All participants were part of a general education classroom. Target behavior was a decrease in pushing classmates. Data collection occurred during baseline, intervention, generalization, and maintenance phases. During computer-assisted social skills

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training (CASST) conditions, the participants read the Social Story at the computer located at the back of their classroom. During paper format conditions, the participants read the Social Story at their desks. Reading the Social Stories occurred during the last five minutes of their reading time, in which observations started once the students finished reading. During the generalization phase, data was collected during the days that followed the intervention to see if the students were able to transfer their skills from during lunch to during recess. During maintenance, teachers were instructed to collect frequency data on the participants target behavior two weeks after the last intervention phase. For this phase, the students were able to choose either CASST or paper format of the Social Story to read, but reading was not required. Furthermore, teacher prompting was also discouraged. Outcomes were measured through observation and daily checklists. Results showed an overall decrease in pushing classmates for all three participants. All three participants decreased their inappropriate behavior following the CASST conditions, but improvement reversed following the paper format. Generalization and maintenance were not demonstrated by all participants. Due to the increase of inappropriate behavior during generalization, all participants required verbal prompts from their teachers. During maintenance, all participants chose to read the Social Story under CASST conditions. However, due to the lack of verbal prompts, inappropriate behavior from all participants eventually returned and increased. Limitations include small sample size and lack of

SYSTEMATIC REVIEW comparison between environments during maintenance. Additionally, cointervention bias was present. Ipad-presented. Vandermeer, Beamish, Milford, and Lang (2013) investigated the effectiveness in presenting a Social Story on an iPad to increase on-task behavior. Level IV single-subject design was used. Participants were three children with ASD who were all 4-years-old. The Social Stories were created on an autism-specific iPad application called Stories2Learn. Each Social Story was personalized and included photographs of the participant demonstrating desired attending and seating behaviors. Data collection occurred

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during baseline, intervention, and withdrawal phases. Baseline and intervention phases occurred for 18 sessions across a 4-week period whereas withdrawal occurred for three additional sessions during the sixth week of the study. During the intervention phase, observation of on-task behavior occurred during tabletop activities, such as puzzles, cutting and pasting, and threading. Two participants were seated in a corner at a semi-circular shaped table, facing the other children, during the activity. Due to anxiety, the third participant sat at a larger table where other children in the class were engaged in typical learning activities. During withdrawal, the Social Stories were taken away. Outcomes were measured through observation and video recordings of the participants. Results of the intervention showed that only the second participant demonstrated a moderate increase in on-task behavior. The first and third participants only demonstrated a small increase in on-task behavior. Withdrawal implementation was not done for these two participants either due to time constraints or being absent during the phase, respectively. Limitations include low external and construct validity and lack of comprehensive information collected about the participants.

SYSTEMATIC REVIEW Discussion Recommendations for Future Research This SR reveals the need for future research regarding increasing social participation through media-based Social Stories. There is a considerable lack of participants within each study which limits the generalizability. Therefore, future research should seek to implement interventions utilizing a larger sample size, which may be difficult due to the individualized nature of Social Stories. Additionally, including a control group can increase the overall validity of the results. Lastly, by prolonging the duration of each intervention, the studies can

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accurately assess whether each participant truly comprehended the target behavior to increase the likelihood of internalizing the overall purpose of the Social Story. Strengths and Limitations of the Systematic Review A strength of this SR is the variety of options for media-based Social Stories that showed effectiveness for children with ASD. In addition, 9 out of the 12 studies used in this SR were completed within the past five years. This recent body of knowledge contributes the evolving diagnosis of ASD. An evident limitation of this SR is the weak levels of evidence due to the lack of randomized control trials. As a result, this SR has low external validity. In addition, only articles that were written in English were included in the study, though one study was completed internationally. Another limitation involves the inclusion criteria set by the researchers. Researchers did not specify a set target behavior to analyze as an outcome of the Social Stories. In addition, a standardized intervention procedure was not considered for the inclusion criteria. Each of the studies used for this SR utilized an intervention that was

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individualized for the child. Researchers also used studies with attention bias and cointervention bias, which limits the overall strength of the SR. Application to Clinical Practice, Education, and Research Although a majority of the studies were not reported in terms of statistical significance, clinical significance of the participants was demonstrated through this SR. This suggests that Social Stories were effective and have the potential to be used in clinical practice. However, it is important to note that all studies included participants with either a mild form of ASD or were higher functioning. As a result, practitioners should take this into consideration before implementing these interventions in clinical practice. This SR also provides additional media-based avenues for practitioners to provide treatment to clients. If a client is not responding to a static-stimulus Social Story, this SR is able to offer insight on outcomes of various strategies through a multimedia-based approach. In regards to application to education and training, this can be incorporated into the curriculum of OT programs when focusing on treatments for social impairments. In regards to research, this SR can contribute to advance the development of Social Stories and provide more effective evidence-based treatment options for children with ASD.

SYSTEMATIC REVIEW References

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American Occupational Therapy Association. (2008).Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625683. American Psychiatric Association. (2013). Neurodevelopmental disorders. In Diagnostic and statistical manual of mental disorders, 5th Edition. Retrieved from http://dsm.psychiatryonline.org.lbproxy2.touro.edu/content.aspx?bookid=556&sectionid=41101757#103436574. doi:10.1176/appi.books.9780890425596.514988 AOTA EBP Project. (2013). Evidence table. Retrieved from https://bbtun.touro.edu/bbcswebdav/pid-1778090-dt-content-rid-1362643_1/xid-1362643_1 Autism Health Insurance Project. (2013). For providers. Retrieved from http://www.autismhealthinsurance.org/for-providers Bernad-Ripoll, S. (2007). Using a self-as-model video combined with social stories to help a child with asperger syndrome understand emotions. Focus on Autism and Other Developmental Disabilities 22(2), 100-106. Brownell, M. D. (2002). Musically adapted Social Stories to modify behaviors in students with autism: four case studies. Journal of Music Therapy, 39(2), 117-144. Hagiwara, T. & Myles, B. S. (1999). A multimedia Social Story intervention: Teaching skills to children with autism. Focus on Autism Other Dev, 14(82), 82-95. doi:10.1177/108835769901400203 Kagohara, D. M., Achmadi, D., Meer, L., Lancioni, G. E., OReilly, M. F., Lang, R.,... Sigafood, J. (2012). Teaching two students with asperger syndrome to greet adults using Social Stories and video modeling. Springer, 241-251. doi:10.1007/s10882-0129300-6

SYSTEMATIC REVIEW Law, M., Stewart, D., Pollock, N., Letts, L., Bosch, J., & Westmoreland, M. (1998). Critical review form quantatitive studies. Retrieved from www.srsmcmaster.ca/Portals/20/pdf/ebp/quanreview.pdf

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Litras, S., Moore, D. W., & Anderson, A. (2010). Using video self-modelled Social Stories to teach social skills to a young child with autism. Autism Research and Treatment, 1-9. doi:10.1155/2010/834979 Mancil, G. R., Hayden, T., Whitby, P. (2009). Differentiated effects of paper and computerassisted Social Stories on inappropriate behavior in children with autism. Focus on Autism and Other Developmental Disabilities, 24(2), 205-215. doi:10.1177/1088357609347324 More, C. (2008). Digital stories targeting social skills for children with disabilities: Multidimensional learning. Intervention in School and Clinic, 43(3), 168-177. doi:10.1177/1053451207312919 OConnor, E. (2009). The use of Social Story DVDs to reduce anxiety levels: A case study of a child with autism and learning disabilities. Support for Learning, 24(3), 134-136. Ozdemir, S., Universitesi, G., Fakultesi, G. E., & Bolumu, O. E. (2008). Using multimedia Social Stories to increase appropriate social engagement in young children with autism. Turkish Online Journal of Educational Technology, 7(3), 80-88. Retrieved from http://tojet.net/articles/v7i3/739.pdf Sansosti, F. J., & Powell-Smith, K. A. (2008). Using computer-presented Social Stories and video models to increase the social communication of children with high-functioning autism spectrum disorders. Journal of Positive Behavior Interventions, 10(3), 162-178. doi:10.1177/1098300708316259

SYSTEMATIC REVIEW Scattone, D. (2007). Enhancing the conversational skills of a boy with aspergers disorder through Social Stories and video modeling. Journal of Autism and Developmental Disorders, 38(2), 395-400. doi:10.1007/s10803-007-0392-2 Spence, S. H. (2003). Social skills training with children and young people: Theory, evidence, and practice. Child and Adolescent Mental Health, 8, 84-95. The Gray Center. (n.d.a). Carol gray. Retrieved from http://www.thegraycenter.org/socialStories/carol-gray The Gray Center. (n.d.b). What are social Stories?. Retrieved from http://www.thegraycenter.org/social-Stories/what-are-social-Stories

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Thiemann, K. S. & Goldstein, H. (2001). Social Stories, written text cues, and video feedback: Effects on social communication of children with autism. Journal of Applied Behavior Analysis, 34(4), 425-446. Vandermeer, J., Beamish, W., Milford, T., & Lang, W. (2013). Ipad-presented Social Stories for young children with autism. Developmental Neurorehabilitation, 1-7. doi:10.3109/17518423.2013.809811

SYSTEMATIC REVIEW Appendix A Levels of Evidence Level of Evidence Number of Articles

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I Randomized Controlled Trials (also systematic reviews, metaanalyses)

II Two groups, non-randomized (cohort, case-control)

III one group, non-randomized (pre- and post-test, before and after)

IV Descriptive studies that include analysis of outcomes (singlesubject design, case series)

V Case reports and expert opinion that include narrative literature reviews and consensus statements

SYSTEMATIC REVIEW Appendix B AOTA Evidence Table

Author/ Year Bernad-Ripoll (2007) Study Objectives Expand the scope of research on emotional recognition by providing direct instruction via video modeling and Social Stories to compensate for the difficulty children and youth with AS experience with generalization Level/Design/Subjects Level IV AB single-subject design with generalization 1 participant 9 years and 8 months old Diagnosed with AS and had a superior range IQ 4th grade and attended a public school Inclusive classroom (general education) and received assistance intermittently throughout the day during certain activities Participant from a Midwestern middle-class community Lived with his parents Father was a university professor Mother was a home maker Intervention and Outcome Measures Intervention: Took place at the participants home Two Social Stories introduced to the participant at each session using photographs that explained the emotion Emotions were either positive or negative Principal investigator would read to the participant the Social Story related to the videotaped segment and then viewed the segment of emotion Reflective questions would be asked to participant Generalization phase was included after the intervention where the participants parents would read a chosen Social Story whenever the participant was having emotional difficulty Outcome measure: How do you feel? Why did you feel like this? What should you do in that situation? Intervention: Facilitated oneon-one with an associate who was also in charge of data collection. Interventions would occur at the designated time stated by the teacher of when the target behavior was most Results Participant was able to correctly apply the emotional label to the videotaped segment with a mean accuracy of 55% at baseline. For the outcome questions, he received a mean accuracy of 10% at baseline. After the intervention, his accuracy rose to 95-100%. Intervention of using videotaped segments of emotions and Social Stories to explain the emotions was effective in teaching a child with AS how to understand and recognize emotions and generalization (Bernad-Ripoll, 2007, p. 103).

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Study Limitations Single-subject design Short duration of the intervention Further research would need to be completed to be able to generalize results to the population of AS and validate its effectiveness

Brownell, M. D. (2002)

Investigate the effect of a musical presentation of social story information on the behaviors of students with autism

Level IV ABAC/ACAB counterbalanced multipletreatment design Four participants between the ages of 6 and 9 All males

Based on frequency of undesired behavior Peter: Baseline upward trend. Reduction when music condition was introduced. Overall, music condition had the lowest results. Significant

Duration of intervention was based on convenience Lack of generalizability Lack of possible musical training to re-implement this study

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Either in the first or second grade All were verbal and had some pre-reading skills Self-contained classroom with same-grade children with ASD All had an affinity for music appreciation Elementary school was in eastern Iowa Selection was completed by teacher referral and positive response to music Inclusion: Had to be the participants first introduction to social Stories Familiarity with this medium would be basis to deem the child excluded from the study. evident. Data collection occurred in the self-contained classroom and participants were taken to a secluded area to minimize distractions. Respective interventions were given to the child, depending on what design they were assigned. Once the condition was complete, the participant would go back to his classroom and observation would commence. Outcome: Peter: TV Talk Brian: Following Directions Nathan: Using a Quiet Voice Justin: Using a Quiet Voice Measures Used: Successive repetition of same vocalization Repetition of instruction presented until Brian followed direction Verbal prompts Verbal prompts/Nonverbal not included difference between baseline and each condition; p= 0.03 and .000. Brian: Baseline had high trend. After first intervention of music condition, trend reduced. Story read condition showed improvement though not very extreme. Significant difference between baseline and each condition; p=.000 and .01. Nathan: Reduction of target behavior after both interventions. Decrease target behavior more evident in music condition. Statistically significant results; p= .03, .000, .04. Justin: Both treatment conditions showed reduced target behavior from baseline. Music condition had more erratic results. Story read condition more stable. Significant difference between baseline and each condition; p= .01 and .01. In all instances either form of the social story was successful in reducing the target behaviors. Overall improvement with hand-washing task but not the on-task behavior. There was some improvement for the ontask behavior in the setting of lunch and the resource room. IT may be possible to use advanced technology with individuals with ASD to teach social skills.

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Hagiwara & Myles (1999)

Investigate the use of social Stories through the medium of presentation to improve target behaviors for children with autism

Level III Single case design 3 participants with various target behaviors (washing hands, on-task behaviors) Autism Suburban elementary school in a Midwestern state Mild to mod. social skill problems

Intervention: Taught basic skills for using computer. Intervention applied to environment 1 with personalized multimedia social story intervention, then move on to environment 2, and 3. Shown social Stories once a day before entering appropriate environment.

Duration of the interventions and lack of consistency in educational environments in which the interventions were conducted

SYSTEMATIC REVIEW
Basic listening/written language skills FM skills 2 7 year olds & 1 9 year old Inclusionary room for most of the school day Level III Multiple baseline design 1 male/1 female participant Aspergers and ADHD Sampling method not stated 10 years old Outcome measure: Washing hands, on-task behaviors measured through anecdotal records and line graphs

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Kagohara, D. M., Achmadi, D., Meer, L., Lancioni, G. E., OReilly, M. F., Lang, R.,... Sigafood, J. (2012) Litras, S., Moore, D. W., & Anderson, A. (2010)

Evaluate the effects of Social Stories and video modeling for teaching two students with Asperger syndrome to greet school staff

Mancil, Hayden, Whitby (2009)

Intervention: Trainer implemented Social Story and video modeling through PowerPoint and iPad Comprehension questions given after to assess attention and comprehension levels Outcome measure: Greeting level/Phase (None/partial/full) Investigate the Level IV Intervention: Naturalistic effectiveness of Single-subject, multiplesetting of Jesses home. combining Social baseline design Participant would watch the Stories and Video Pseudonym of Jesse target video three time a day Self-Modelling (VSM) to 3 years and 5 months old (morning, afternoon, early teach social skills to a Received a formal evening). Videos 3-5 minutes three-year-old child with developmental assessment each. Showed Target Behavior autism Deficits in language, and videos from previous socialization, and phases. Parents would repetitive/obsessive behaviors facilitate these viewing Pilot testing showed that sessions with instructional Jesse did not respond delivery and would fill out positively to verbal reading procedural checklists to satisfy of Social Stories treatment fidelity in regards to General aversion to being adherence to protocol. read to which made him a Outcome measure: Greeting candidate for VSM. Making invitation to play Contingent response Verbal/communicative behavior Social engagement/interaction Is media-based social Level IV Intervention: Seven phase Stories more effective ABABCBC multicomponent intervention utilizing CASST in increasing social design Outcome measure: decrease in participation for children 3 children with autism pushing classmates through a

Both show increase from baseline. Overall, a higher number of full greetings than partial greetings over the course of the study.

Inability to control for confounding variables (monitoring morning schedules, school absences/infrequency, time constraints)

Social initiations generalized and observed in novel situations Effectiveness shown in greeting, inviting to play, and contingent responding VSM Social Stories is a promising intervention because it is straightforward and efficient. Implications of these results for practice show the support for combining Social Stories with other methods to teach social skills to children with autism

Low sample size Low external validity and generalizability

Decrease in pushing classmates when presented with Social Stories in CASST format

Cointervention not addressed Small sample size, lack of comparison to a verbal prompt without a Social Story to

SYSTEMATIC REVIEW
with autism spectrum disorder than paperbased social Stories? OConnor (2009) Ages 6-9 (K-1st grade) daily checklist

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decrease inappropriate behavior between environments, inclusion of verbal prompts to decrease inappropriate behavior instead of exclusively Social Stories No limitations discussed in the study However, selection bias is evident

Examine the use of Social Story DVDs as a single-intervention approach in addressing the issue of anxiety around turn-taking in a child with AD and LD

Level IV Case study design 1 male participant AD and LD Client of the author Presents with social isolation and aggression

Ozdemir, S., Universitesi, G., Fakultesi, G. E., & Bolumu, O. E. (2008)

The purpose of the study was to examine the effectiveness of the multimedia social Stories on the duration of appropriate social engagement of 3 young children.

Level III Single Case Design Three children with autism (John: 6 years and 2 months old and a male Caucasian, Gerard: 6 years and 4 months old and a male Caucasian, Kenny: 5 years and 6 months old and an African-American male)

Sansosti, F. J., & PowellSmith, K. A. (2008)

The purpose of the study was to investigate the effects of computerpresented Social Stories and video models on the social communication skills of three children with HighFunctioning

Level III Single case design Three boys Autism (Vito: 6yrs 6mos old, kindergarten in general ed, Michael: 9yrs 3mos old, second grade in general ed, Santino: 8yrs 10mos old, third grade in intermediate

Intervention: Observation over a 3 week period. Social Story DVD used and turn-taking games 15 minutes before PE and swimming lesson. Turntaking game played with peer on bus ride to pool. Visual reminders utilized. Outcome measure: Triggers, duration, intensity of behavior measured by STAR approach Intervention: A multimedia social story was administered for each participant. Each social story included information about that particular play activity and is followed by short movies that correspond to the social story sentence on each page. After reading, participant played in play area for 10 minutes with a typical peer. Outcome measure: social engagement codes and line graph Intervention: One social story and then one video were administered for each participant. Each video had target behavior modeled by similar-aged peer. After being shown the Social Story, the participant was then sent to their targeted social setting

Participants overall levels of intensity did not decrease during PE but did for swimming. Deemed generalization of what is learned was not observed with subject.

Increased the duration of appropriate social engagement for all participants. Participants spend longer time socially engaged with peers. Only participants John and Gerard only showed generalization.

Limitations include nonconformity of many of the recommended guidelines, flawed and weak research designs, and confounding effects as additional interventions also implemented social Stories.

Two participants required teacher prompting in addition to original intervention. Improved rates of social communication. Demonstrated maintenance of skills during the 2-week follow up. Generalization of skills only observed for Vito, but only

Combination of social Stories and video modeling; adding teacher prompting and student confederates; reinforcement in the participants environments was not assessed; follow-up only lasted two weeks; small sample size

SYSTEMATIC REVIEW
Autism/Aspergers syndrome (HFA/AS) within general education environments. Language Learning Disabled (LLD)/ Varying Exceptionalities (VE) classroom that included typically developing students during the entire school day) Level III Single case design 1 participant 9-year-old boy Asperger syndrome Referred to a clinic in the South by his mother for difficulties with social interactions Outcome measure: Direct observation system to code the occurrence of target behaviors using 15-second partialinterval recording, and Peer Comparison data Intervention: One social story created for each target skill (eye contact, smiling, and initiations. The wording of each page was shown in the video and narrated by an adult. After the story was narrated, two adults modeled the target skill during a five minute video taped conversation. Matthew viewed each videotaped social story initially in the clinic setting. Watching at home then added. He would have a conversation with an adult in the clinic. Outcome measure: 5-min observations. Researchers cued by an audio every 10 seconds to record the occurrence of the target behaviors. The data was scored from the video tapes. Intervention: Occurred in media room in the schools library. Triads attended treatment separately. Baseline; participants rotated between 3 social activities. Treatment sessions consisted of 10 minute systematic instructions, 10 minutes of engagement in a social activity, and 10 minutes of self-evaluation using video feedback. Examiner reads after prompting was added to his intervention.

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Scattone, D. (2007).

The purpose of the study is to examine the effects of combining social Stories with video modeling as a treatment on conversational skills for a boy with Aspergers syndrome.

PND for eye contact and reciprocal interactions were 100%, making it highly effective outcome. However, PND for smiling was 32%, making it unreliable. Therefore, Matthew improved in terms of eye contact and reciprocal interactions, but not smiling.

Utilizing two components of one intervention making it difficult to determine how each component contributes to the effectiveness of the social story; only one pre-intervention and one generalization probe; having only one participant; short observation time of five minutes; lack of typical peers in the study.

Thiemann, K. S. & Goldstein, H. (2001)

Investigate the effects of written text and pictorial cuing with supplemental video feedback on the social communication of 5 students with autism and social deficits

Level III Multiple-baseline design 5 children with social impairments and 10 peers without disabilities Same elementary All were put into a triad (1 child with social impairment, 2 peers without disability). Focus on 5 children; between 6 years 6 months to 12 years 2 months, and grades 1

Dan- during baseline he showed few attention-securing behaviors but this improved his treatment. His intervention involved initiating comments and securing attention. Greg- had low rates for securing attention but with treatment, he had improved results. Overall, his average rate of inappropriate social behaviors decreased by almost

Short intervention duration

SYSTEMATIC REVIEW
child the agenda and discusses rules and tasks for the activity. Time set for 10 minutes. Examiner leaves table. Data collection began. Peer orientation would occur after baseline with the 2 peers without disabilities. Treatment transpired using social Stories, text cues, and pictures of social skills. Instructional period, social interaction, video-taped feedback. Outcome measure: Contingent responses Securing attention Initiating comments Initiating requests Frequency of inappropriate discourse skills (Inappropriate topic change) Unintelligible Other No response Vandermeer, Investigate the Level IV Sit at a semi-circular shaped Beamish, effectiveness in Single-subject design table while engaging in Milford, & presenting a social story 3 participants with autism tabletop activities and Lang (2013) on an iPad to increase the Queensland, Australia Stories2Learn app was used on-task behavior of Echolalia, tantrums, and Outcome measure: on-task young children with anxiety observed behaviors measured through a autism Level Flip Video camera and observation For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com through 5 All registered with the Florida State Universitys Center for Autism and Related Disabilities. Inclusion included 1impaired social communication; 2- emerging or acquired wordidentification skills; 3functional verbal communication; 4- full or partial inclusion in regular education. 50% after treatment was implemented on the first social skill (Thiemann & Goldstein, 2001, p. 435). John & Casey- combined for baseline, performed very low. Immediate treatment effects were observed for John for initiations and securing attention (Thiemann & Goldstein, 2001, p. 435). Casey had slight improvements following treatment on securing attention.

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iPad-presented social Stories can increase on-task behavior of young children with autism during table-top activities over a brief implementation period but it may only work on some children

Low external and construct validity as well as a lack of collected data comprehensive information about participant characteristics during recruitment