Social Stories for children with disabilities

Impact of Social Stories on social and emotional health of autism spectrum primary school children: the ASSSIST2 RCT with economic evaluation

Background

Differences in the way autistic children experience the world can contribute to anxiety and stress. Carol Gray's Social Stories™ are a highly personalised intervention to support children by providing social information about specific situations in an individual story.

Objectives

This randomised controlled trial aimed to establish whether Social Stories are clinically effective and cost-effective in improving social responsiveness and social and emotional health in children on the autism spectrum in schools.

Design

A multisite pragmatic cluster randomised controlled trial comparing Social Stories with care as usual.

Setting

Eighty-seven schools (clusters) across Yorkshire and the Humber.

Participants

Two hundred and forty-nine children were randomised via a bespoke system hosted at York Trials Unit (129 Social Stories and 120 care as usual). Recruitment was completed in May 2021. Participants were children aged 4-11 years with a diagnosis of autism, alongside teachers, interventionists and caregivers. Recruitment was via schools, NHS trusts, support groups and local publicity.

Intervention

The intervention included training for educational professionals and caregivers covering psychoeducation and implementation of Social Stories. Stories were written around contextualised goals around the child's need for social information. Interventionists read the Social Story™ with the child at least six times over 4 weeks during school.

Main outcome measure

The primary outcome was the Social Responsiveness Scale-2 completed by teachers at 6 months (the primary end point), which measures social awareness, cognition, communication and behaviour. Data were collected from caregivers and educational professionals at 6 weeks and 6 months through questionnaires. Blinding of participants was not possible.

Results

At 6 months, the estimated difference in expected teacher-reported Social Responsiveness Scale-2 T-score (the primary end point) was -1.61 (95% confidence interval -4.18 to 0.96, p = 0.220), slightly favouring the intervention group. The estimated differences for the parent-reported secondary outcomes at 6 months were small and generally favoured the control group except the measure of children's quality-adjusted life-year (+ 0.001, 95% confidence interval -0.032 to 0.035) and parental stress (-1.49, 95% confidence interval -5.43 to 2.46, p = 0.460), which favoured the intervention group. Children in the intervention group met their individual goals more frequently than children who received usual care alone (0.97 confidence interval 0.21 to 1.73, p = 0.012). The intervention is likely to save small costs (-£191 per child, 95% confidence interval -767.7 to 337.7) and maintain a similar quality of life compared to usual care. The probability of Social Stories being a preferred option is 75% if the society is willing to pay £20,000 per quality-adjusted life-year gained. Limitations include considerable disruptions during the coronavirus disease 2019 pandemic.

Conclusion

Social Stories are used in schools and represent a low-cost intervention. There is no clinically evident impact on social responsiveness, anxiety and/or depression, parental stress or general health. Benefits were observed for specific behavioural goals as assessed by the teacher, and Social Stories may serve as a useful tool for facilitating dialogue between children and school staff to address specific behavioural challenges. Usage should be at the school's discretion.

Future work

Given the uncertainty of the results in light of coronavirus disease 2019, further work to establish the impact of Social Stories is merited.

Trial registration

This trial is registered as ISRCTN11634810.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/111/91) and is published in full in Health Technology Assessment; Vol. 28, No. 39. See the NIHR Funding and Awards website for further award information.

Cost-utility analysis of Social Stories™ for children with autism spectrum disorder in mainstream primary schools: results from a randomised controlled trial

BACKGROUND

One in 57 children are diagnosed with autism in the UK, and the estimated cost for supporting these children in education is substantial. Social Stories™ is a promising and widely used intervention for supporting children with autism in schools and families. It is believed that Social Stories™ can provide meaningful social information to children that can improve social understanding and may reduce anxiety. However, no economic evaluation of Social Stories has been conducted.

AIMS

To assess the cost-effectiveness of Social Stories through Autism Spectrum Social Stories in Schools Trial 2, a multi-site, pragmatic, cluster-randomised controlled trial.

METHOD

Children with autism who were aged 4-11 years were recruited and randomised (N = 249). Costs measured from the societal perspective and quality-adjusted life-years (QALYs) measured by the EQ-5D-Y-3L proxy were collected at baseline and at 6-month follow-up for primary analysis. The incremental cost-effectiveness ratio was calculated, and the uncertainty around incremental cost-effectiveness ratios was captured by non-parametric bootstrapping. Sensitivity analyses were performed to evaluate the robustness of the primary findings.

RESULTS

Social Stories is likely to result in a small cost savings (-£191 per child, 95% CI -767.7 to 337.7) and maintain similar QALY improvements compared with usual care. The probability of Social Stories being a preferred option is 75% if society is willing to pay £20 000 per QALY gained. The sensitivity analysis results aligned with the main study outcomes.

CONCLUSIONS

Compared with usual care, Social Stories did not lead to an increase in costs and maintained similar QALY improvements for primary-aged children with autism.

A rule-based theoretical account of social stories to address the double empathy problem

Social Stories™ (SS) is one of the most popular and researched interventions for autistic children. To date, research that focuses on outcomes has been prioritized over the investigation of the psychological mechanisms that inform the intervention. In this article we consider theoretical accounts proposed thus far which could underpin SS. We argue that mechanisms that are based on social deficit theories lack validity, and propose a rule-based theoretical account to inform a strengths-based approach toward conceptualizing the mechanisms that underpin SS. We apply this account to the 'double-empathy problem' to propose that SS can be adapted to involve all parties in the development and delivery of SS support by adopting a rule-based perspective. We use the example of systemizing (the drive to analyze and explore systems in terms of 'if-and-then' rules), which is proposed to be a relative autistic strength, as a form of rule-based thinking that can provide a theoretical account of SS and a framework to address the double-empathy problem.

"A scoping review: Social stories supporting behavior change for individuals with Autism"

Social Stories (also known as social narratives) help individuals participate in and understand social situations. This scoping review identifies and synthesizes social narrative research targeting behavior change in individuals with ASD. Using the following questions as a guide: (a) What is the scope of social narrative interventions used for individuals with ASD, (b) What behavior change outcome measures are evaluated, and (c) What research designs are used; five databases were searched from 2007-to-2018. Fifty-six articles met the criteria. Primary outcomes were sorted into two macro-categories: Reduce Disruptive Behaviors and Increase Desired Behaviors. Most, but not all, studies were found to be effective for various behaviors such as aggressive actions, verbal protests, identifying emotions, executive functioning, following directions, and responding in social situations. Social narratives can be used to promote skills/behaviors in individuals with ASD to enable participation, an important goal in occupational therapy practice. They are an accessible and feasible intervention that can be implemented in various settings for behaviors including activities of daily living, social skills, independence, and self-regulation. Most research reviewed the single subject design, which is a limitation of the research as it makes results difficult to generalize. However, through replication, functional relationships can be determined. Additional research utilizing randomized control trials is recommended.

Reflecting the trends in the academic landscape of special education using probabilistic dynamic topic modeling

Purpose

Special education is the education segment that deals with the students facing hurdles in the traditional education system. Research data have evolved in the domain of special education due to scientific advances. The present study aims to employ text mining to extract the latent patterns from the scientific data.

Design/methodology/approach

This study examined the 12,781 Scopus-indexed titles, abstracts and keywords published from 1987 to 2021 through an integrated text-mining and topic modeling approach. It combines dynamic topic models with highly cited reviews of this domain. It facilitates the extraction of topic clusters and communities in the topic network.

Findings

This methodology discovered children’s communication and speech using gaming techniques, mental retardation, cost effect on infant birth, involvement of special education children and their families, assistive technology information for special education, syndrome epilepsy and the impact of group study on skill development peers or self as the hottest topic of research in this domain. In addition to finding research hotspots, it further explores annual topic proportion trends, topic correlations and intertopic research areas.

Originality/value

The results provide a comprehensive summary of the popularity of research topics in special education in the past 34 years, and the results can provide useful insights and implications, and it could be used as a guide for contributors in special education form a structured view of past research and plan future research directions.

Psychometric Properties of Standardized Instruments that are Used to Measure Pragmatic Intervention Effects in Children with Developmental Language Disorder: A Systematic Review

This review aimed to analyze the psychometric properties of standardized instruments that are used to measure pragmatic intervention effects in children with developmental language disorder. Following PRISMA structure, a comprehensive literature research was conducted in five electronic indexing databases: Central, PubMed, Medline, Web of Science and Scopus. Six studies between 2005 and 2019 were included and seven standardized instruments have been analyzed. All instruments present some evidence of validity and reliability, but none reported responsiveness. The instruments reviewed were not used for their original purpose, which may explain the results. The small number of studies prevent drawing clear conclusions. Future studies should focus on appropriate, valid, reliable, and responsive measures. Research focusing on psychometric properties is crucial, mostly about responsiveness.

The impact of using digitally-mediated social stories on the perceived competence and attitudes of parents and practitioners supporting children with autism

A Social Story (SS) is a highly acceptable and widely used intervention by the autism community. Yet, inconsistent implementation of the intervention is reported to be one of the causes of variability in terms of outcome research, particularly in a naturalistic context. This study aimed to (1) investigate whether digitally-mediated social stories (SSs) can improve competence in developing and delivering a SS and thus contribute towards improved implementation, and (2) investigate the impact of the digitally-mediated SS on attitudes towards the SS intervention. Ninety-three participants took an initial pre-engagement survey. Forty-eight of these participants also complete a post-engagement survey. A pre-post design was utilised with the participants who completed both surveys. These 48 participants were invited to develop a digitally-mediated SS with the aim of exploring how digitally-mediated SSs impacted perceived competence and attitudes. Post-engagement data was collected two weeks after the pre-engagement data. Outcomes of this study indicate that both perceived competence and attitudes improved after engaging with digitally-mediated SSs. It is concluded that digitally-mediated SS not only impacted the integrity of how the intervention was delivered but also the beliefs in the participants’ capabilities to develop and deliver a SS. Digitally-mediated SS, thus, has the potential to effectively support development and delivery whilst also addressing challenges related to intervention implementation in a naturalistic context.

Mothers' and practitioners' insights on the use of digitally-mediated social stories with children on the autism spectrum: A convergent mixed-methods study

BACKGROUND

While end-user interest in digitally-mediated Social Story (SS) intervention for children on the autism spectrum is growing, research on the use of SSs in digital form is currently lacking.

AIMS

This study aimed to investigate how digital-mediation can influence parents' and practitioners' attitudes towards the SS intervention as well as impact their perceived competence in their ability to administer the intervention.

METHODS AND PROCEDURES

This study used a convergent mixed-method design. Nineteen participants (ten practitioners and nine mothers) participated in two focus group sessions. Participants then engaged with a digitally-mediated SS and completed a pre- and post-engagement survey measuring attitude, competence and user experience with the intervention.

OUTCOMES AND RESULTS

The mothers' perceived competence ratings improved after engaging with digitally-mediated SSs. Mothers and practitioners also indicated that digitally-mediated SSs increased their perceived efficiency, while mothers felt it improved their autonomy and further empowered them as end-users.

CONCLUSION AND IMPLICATIONS

Digitally-mediated SS has the potential to effectively address challenges related to intervention implementation whilst also empowering further the end-user.

Virtual voice assistant applications improved expressive verbal abilities and social interactions in children with autism spectrum disorder: a Single-Subject experimental study

The use of interactive technologies has been demonstrated to enhance verbal and non-verbal communication, as well as the social interaction tendencies of children with Autism Spectrum Disorder (ASD). We examined effects of using Virtual Voice Assistant (VVAs) in children with ASD with respect to two outcomes: speech skills and social interaction skills. A single-case study included three children with ASD (4-11 years old) that utilized VVAs for three months. Pre- and post-intervention questionnaires and semi-structured interviews were used to measure the communication and social interaction skills of the participating children. Participant One, Two and Three showed improvement in the number of correct words produced the VVA intervention. All participants showed increases in social interactions in the intervention phase. Overall, the results showed that the VVAs had positive effects on the speech and social interaction skills of autistic children. The findings demonstrate that children with ASD may benefit from VVAs to improve their communication skills.

Autism Spectrum Disorder and Social Story Research: a Scoping Study of Published, Peer-Reviewed Literature Reviews

Social Stories (SS) is a widely used intervention for children on the autism spectrum. A search of databases (CINAH EBSCO, A+Eductaion, ERIC, Education Source, PsyINFO, PubMed, Science Direct, Scopus, Web of Science, and ABI Inform Global) identified that, since its development over 25 years ago, the research exploring SS has been reviewed 17 times. These reviews include synthesis of literature; systematic reviews, meta-analyses; comparative reviews; and descriptive reviews. A scoping review of these 17 literature reviews identified 5 major themes: (1) research design of SS studies, (2) effectiveness of SS, (3) factors influencing outcomes of SSs, (4) social validity of SS interventions, and (5) maintenance and generalisation of SS outcomes. Future recommendations related to SS research were also identified.

A Pilot Randomised Control Trial of Digitally-Mediated Social Stories for Children on the Autism Spectrum

Social stories is a widely used intervention for children on the autism spectrum, particularly within an educational context. To date, systematic reviews and meta analyses of the research evaluating social stories has produced mixed results, often due to a lack of methodological rigour and variability in the development and delivery of the social stories. To address the gap in methodological rigour, a pilot Randomised Control Trial (RCT) was conducted, incorporating a social stories intervention group (n = 9 children on the autism spectrum) and an attentional control group who received a poem (n = 6 children on the autism spectrum) using a digital platform to address variability. Digitally-mediated social stories were found to be effective in producing beneficial changes in behaviour outcomes, which were sustained at a six-week follow up.

Autism Spectrum Social Stories In Schools Trial 2 (ASSSIST2): study protocol for a randomised controlled trial analysing clinical and cost-effectiveness of Social Stories™ in primary schools

Background

Interventions designed to support children with a diagnosis of Autism Spectrum Conditions (ASC) can be time consuming, needing involvement of outside experts. Social Stories™ are a highly personalised intervention aiming to give children with ASC social information or describing an otherwise difficult situation or skill. This can be delivered daily by staff in education settings. Studies examining Social Story™ use have yielded mostly positive results but have largely been single case studies with a lack of randomised controlled trials (RCTs). Despite this numerous schools are utilising Social Stories™, and a fully powered RCT is timely.

Methods

A multi-site pragmatic cluster RCT comparing care as usual with Social Stories™ and care as usual. This study will recruit 278 participants (aged 4–11) with a clinical diagnosis of ASC, currently attending primary school in the North of England. Approximately 278 school based staff will be recruited to provide school based information about participating children with approximately 140 recruited to deliver the intervention. The study will be cluster randomised by school. Potential participants will be screened for eligibility prior to giving informed consent. Follow up data will be collected at 6 weeks and 6 months post randomisation and will assess changes in participants’ social responsiveness, goal based outcomes, social and emotional health. The primary outcome measure is the Social Responsiveness Scale Second Edition (SRS-2) completed by school based staff at 6 months. Approvals have been obtained from the University of York’s Research Governance Committee, Research Ethics Committee and the Health Research Authority. Study results will be submitted for publication in peer-reviewed journals and disseminated to participating families, educational staff, local authority representatives, community groups and Patient and Participant Involvement representatives. Suggestions will be made to NICE about treatment evidence dependent on findings.

Discussion

This study addresses a much used but currently under researched intervention and results will inform school based support for primary school children with a diagnosis of ASC.

Trial registration

The trial is registered on the ISRCTN registry (registration number: ISRCTN11634810). The trial was retrospectively registered on 23rd April 2019.

Effectiveness of Social Stories in Teaching Abduction-Prevention Skills to Children with Autism

The purpose of the present study was to examine the effectiveness of social stories in teaching abduction-prevention skills to children with autism spectrum disorder (ASD). Three male participants with ASD, aged 4-12 years, participated in the study, which was conducted using a multiple-probe-across-participants design. Thirty-nine voluntary adults participated in the study as strangers who presented lures to the participants. The findings of the study showed that social stories were effective on promoting acquisition for all students with ASD. All the participants were able to learn the target skill and maintain their learning. Social validity data were also collected from participants and their parents. Social validity findings revealed that the opinions of the participants and their parents were positive overall.

Emotion regulation and intervention in adults with autism spectrum disorder: a synthesis of the literature

Purpose

Emotion regulation is an ongoing multiprocess phenomenon and is a challenging developmental task to acquire in individuals with autism spectrum disorder (ASD) who have different neurobiological profiles and emotion regulation problems. The purpose of this paper is to review recent literature to understand the neurobiological and psychological perspective of emotion regulation in ASD, while converging themes of psychosocial interventions and existing best practices on emotion regulation within this heterogeneous population are reviewed and discussed in consideration of intellectual disability (ID).

Design/methodology/approach

Review of recent literature and common empirically supported interventions addressing emotional regulation implemented in individuals with and without ASD, and with and without ID were included in the electronic database search through PubMed, EBSChost, Science Direct, Wiley Online Library, GALE and SAGE. Search terms used included autism, ID, cognitive control, executive function, sensory processing/intervention, emotion regulation, cognitive behavior therapy, mindfulness, social stories, positive behavior support and behavior therapy.

Findings

Neural systems governing emotion regulation can be divided into “top-down” and “bottom-up” processing. Prefrontal cortex, cognitive and attentional control are critical for effective emotion regulation. Individuals with ASD, and with ID show impairments in these areas have problems with emotion regulation. Targeted psychosocial intervention need to consider bottom-up and top-down processes of emotion regulation, and that standardized interventions require adaptations.

Originality/value

There are limited studies looking into understanding the neurobiological and psychological perspective of emotion regulation in ASD and linking them to interventions. This review highlights psychosocial interventions that are important for further research, investigation and development as treatment in this population is limited.

Social Stories for Children with Autism Spectrum Disorder: Validating the Content of a Virtual Reality Program

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that affects socio-emotional skills and perspective-taking abilities. Although social stories in a form of virtual reality program can help children with ASD, developing them and identifying appropriate responses might be subjective and thus challenging. Using Delphi method, and guided by general case training, we involved 63 parents and clinicians of individuals with ASD, in two rounds of online iteration to refine the stories. Scenarios that reached a 75% agreement level were accepted. This project is the first study to develop and validate a library of 75 short socio-emotional stories that illustrate various types and intensities of emotion in three social contexts of home, school, and community as the content of a virtual reality program.

A treatment comparison study of a photo activity schedule and Social Stories for teaching social skills to children with Autism Spectrum Disorder: brief report

PURPOSE

To compare the efficacy of two procedures, a photo activity schedule intervention and Social Stories, to teach social skills to four children diagnosed with Autism Spectrum Disorder (ASD).

METHODS

An adapted alternating treatments design with an additional multiple baseline control was used, and two social skills were targeted for each of the four participants, one under each intervention condition.

RESULTS

Results indicated that all four participants learned the target social behaviours with the photo activity schedule intervention, but did not learn target social behaviours with Social Stories.

CONCLUSIONS

Findings support the use of a photo activity intervention for teaching social skillsto children with ASD; we discuss the implications of inconsistent findings of effectiveness of Social Stories.

Eye gaze and pupillary response in Angelman syndrome

BACKGROUND

Angelman syndrome (AS) is a rare neurological disorder characterized by severe developmental disability, communication impairment, elevated seizure risk, and motor system abnormalities.

AIMS

The aims of this study were to determine the feasibility of social scene eye tracking and pupillometry measures in individuals with AS and to compare the performance of AS participants to individuals with idiopathic Autism Spectrum Disorder (ASD) and typically developing controls (TDC).

METHODS AND PROCEDURES

Individuals with AS and age- and gender- matched controls completed a social eye tracking paradigm. Neurobehavioral characterization of AS participants was completed via a battery of psychological testing and caregiver behavioral evaluations.

OUTCOMES AND RESULTS

Eight of seventeen recruited AS participants completed the eye tracking paradigm. Compared to TDC, AS subjects demonstrated significantly less preference for social scenes than geometric shapes. Additionally, AS subjects showed less pupil dilation, compared to TDC, when viewing social scenes versus geometric shapes. There was no statistically significant difference found between AS and ASD subjects in either social eye tracking or pupillometry.

CONCLUSIONS AND IMPLICATIONS

The use of eye tracking and pupillometry may represent an innovative measure for quantifying AS-associated impairments in social salience.

Neuroscience-Based Approaches to Teaching Students on the Autism Spectrum

Abstract. An understanding of the relationship between emotions, cognition, and learning can provide insight into learning needs for children with autism spectrum disorder (ASD). This article discusses current research and new theories on ASD from three different perspectives: the behavioral sciences, neuroscience, and education. The rapid increase of ASD diagnoses in children worldwide, and an understanding of autism as one of the developmental disorders affecting a spectrum of neural networks in a growing brain, indicates that educational implications from the combined insights may strengthen the development of strategies and interventions not only for ASD individuals, but for neurotypical children as well.

Social Stories™ to alleviate challenging behaviour and social difficulties exhibited by children with autism spectrum disorder in mainstream schools: design of a manualised training toolkit and feasibility study for a cluster randomised controlled trial with nested qualitative and cost-effectiveness components

BACKGROUND

A Social Story™ (Carol Gray) is a child-friendly intervention that is used to give children with autism spectrum disorders (ASDs) social information in situations where they have social difficulties. Limited evidence mainly using single-case designs suggests that they can reduce anxiety and challenging behaviour.

OBJECTIVES

The objectives were to conduct a systematic review, use this to develop a manualised intervention and run a feasibility trial to inform a fully powered randomised controlled trial (RCT) on their clinical effectiveness and cost-effectiveness in schools.

DESIGN

This is a three-stage study following the Medical Research Council framework for complex interventions. Specifically, it involved a theoretical phase, a qualitative stage and a feasibility trial stage.

SETTING

Qualitative interviews and focus groups took place in Child and Adolescent Mental Health Service and primary care settings. The feasibility study took place in 37 local mainstream schools.

PARTICIPANTS

Fifty children (aged 5-15 years) in mainstream school settings with a diagnosis of ASD were entered into the trial. For each child, an associated teacher and parent was also recruited.

INTERVENTIONS

The intervention was a goal-setting session followed by a manualised toolkit (including a training session) for creating Social Stories™ for use with school-aged children. The comparator treatment was a goal-setting session followed by an attention control. Both arms received treatment as usual.

MAIN OUTCOME MEASURES

Outcomes tested as part of the feasibility study included child- and proxy-completed questionnaires for mental health, quality of life and goal-based outcome measures. Adults additionally completed behaviour diaries and the parental stress index.

RESULTS

The review found that the research into social stories is predominantly based in the USA, carried out in under-12-year-olds and using single-case designs. Most studies either did not follow established Social Story criteria or did not report if they did. The assessment of effectiveness presents a largely positive picture but is limited by methodological issues. There were no adequate RCTs and insufficient information to assess a number of important sources of potential bias in most studies. A manualised intervention was produced using an iterative process between user focus groups and a writing team, and assessed in the feasibility study. All 50 participant groups were recruited within the study time frame. Two outcome measures, the Social Responsiveness Scale-2 and the custom-made goal-based measure, showed high levels of completion rates and appeared to be capturing social and behaviour skills targeted by the use of Social Stories. Detailed recommendations for a full trial are provided.

LIMITATIONS

Blinding of participants was not feasible. Treatment fidelity was not assessed because of low levels of story return rates.

CONCLUSIONS

The study showed that a fully powered RCT is feasible with an extended geographical footprint. A large amount of data and information has helped to inform the design of this RCT, which will be the subject of a future research grant application. Future work could focus on developing an appropriate blinded outcome measure for this population.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001440.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN96286707.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 6. See the NIHR Journals Library website for further project information.

Social Stories in mainstream schools for children with autism spectrum disorder: a feasibility randomised controlled trial

OBJECTIVES

To assess the feasibility of recruitment, retention, outcome measures and intervention training/delivery among teachers, parents and children. To calculate a sample size estimation for full trial.

DESIGN

A single-centre, unblinded, cluster feasibility randomised controlled trial examining Social Stories delivered within a school environment compared with an attentional control.

SETTING

37 primary schools in York, UK.

PARTICIPANTS

50 participants were recruited and a cluster randomisation approach by school was examined. Participants were randomised into the treatment group (n=23) or a waiting list control group (n=27).

OUTCOME MEASURES

Acceptability and feasibility of the trial, intervention and of measurements required to assess outcomes in a definitive trial.

RESULTS

An assessment of the questionnaire completion rates indicated teachers would be most appropriate to complete the primary outcome measure. 2 outcome measures: the Social Responsiveness Scale (SRS)-2 and a goal-based measure showed both the highest levels of completion rates (above 80%) at the primary follow-up point (6 weeks postintervention) and captured relevant social and behaviour outcomes. Power calculations were based on these 2 outcome measures leading to a total proposed sample size of 180 participant groups.

CONCLUSIONS

Results suggest that a future trial would be feasible to conduct and could inform the policy and practice of using Social Stories in mainstream schools.

TRIAL REGISTRATION NUMBER

ISRCTN96286707; Results.

iPad-presented social stories for young children with autism

OBJECTIVE

This study investigated the effectiveness of iPad-presented social stories in increasing the on-task behaviour of three young children with autism.

METHOD

A single-subject with multiple baseline across participants design was employed with three 4-year-old children to assess intervention effectiveness during structured table top activities. Observational data were digitally recorded, scored, graphed, and interpreted using 10-second interval measures over 5-min periods across baseline, intervention, and withdrawal phases.

RESULTS

The combination of the social story together with the iPad proved to be an effective intervention for one of the three child participants. These findings confirm that the intervention may be effective with some children, but not others.

CONCLUSION

Overall, this study builds on existing research that supports social stories as a promising practice. Further research into the use of iPad-presented social stories, particularly for children of varying ages, abilities, and learning styles is recommended.

Using tablet assisted Social Stories™ to improve classroom behavior for adolescents with intellectual disabilities

The present study examined the use of tablet assisted Social Stories™ intervention for three high school students with severe intellectual disabilities whose problem behavior interfered with their learning and caused classroom disruptions. A multiple probe design across participants was employed to test the impact of the tablet assisted SS on the participants' target behaviors. During intervention, the participants read the Social Stories that were created on Prezi and accessed via Quick Response (QR) codes using a Galaxy Tap smart tablet before participating in an academic period. Data indicated that the SS intervention decreased disruptive behavior and increased academic engagement in all three participants. All three demonstrated generalization of behaviors to a nontargeted academic period and maintenance of improved behaviors at the 2-week follow-up.

Autism Spectrum Social Stories In Schools Trial (ASSSIST): study protocol for a feasibility randomised controlled trial analysing clinical and cost-effectiveness of Social Stories in mainstream schools

INTRODUCTION

Current evidence suggests that Social Stories can be effective in tackling problem behaviours exhibited by children with autism spectrum disorder. Exploring the meaning of behaviour from a child's perspective allows stories to provide social information that is tailored to their needs. Case reports in children with autism have suggested that these stories can lead to a number of benefits including improvements in social interactions and choice making in educational settings.

METHODS AND ANALYSIS

The feasibility of clinical and cost-effectiveness of a Social Stories toolkit will be assessed using a randomised control framework. Participants (n=50) will be randomised to either the Social Stories intervention or a comparator group where they will be read standard stories for an equivalent amount of time. Statistics will be calculated for recruitment rates, follow-up rates and attrition. Economic analysis will determine appropriate measures of generic health and resource use categories for cost-effectiveness analysis. Qualitative analysis will ascertain information on perceptions about the feasibility and acceptability of the intervention.

ETHICS AND DISSEMINATION

National Health Service Ethics Approval (NHS; ref 11/YH/0340) for the trial protocol has been obtained along with NHS Research and Development permission from Leeds and York Partnership NHS Foundation Trust. All adverse events will be closely monitored, documented and reported to the study Data Monitoring Ethics Committee. At least one article in a peer reviewed journal will be published and research findings presented at relevant conferences.

TRIAL REGISTRATION NUMBER

ISRCTN96286707.

Do Social Stories help to decrease disruptive behaviour in children with autistic spectrum disorders? A review of the published literature

A structured search and identification of themes within the literature regarding the use of Social Stories to decrease disruptive behaviour in children with autistic spectrum disorders is presented. The examination of seven studies showed that the Social Story intervention was successful for the majority of the participants, although the level of success was variable. Overall, Social Stories appear to be an acceptable intervention for use in the classroom, however unplanned verbal prompting by teachers, in some studies, reduced confidence in the effectiveness of Social Stories when used in isolation. An increasing body of literature has indicated that Social Stories are an effective intervention for children diagnosed with autistic spectrum disorders, however very few studies have addressed the efficacy of Social Stories when used with children with other disabilities.

Innovative technology-based interventions for autism spectrum disorders: a meta-analysis

This article reports the results of a meta-analysis of technology-based intervention studies for children with autism spectrum disorders. We conducted a systematic review of research that used a pre-post design to assess innovative technology interventions, including computer programs, virtual reality, and robotics. The selected studies provided interventions via a desktop computer, interactive DVD, shared active surface, and virtual reality. None employed robotics. The results provide evidence for the overall effectiveness of technology-based training. The overall mean effect size for posttests of controlled studies of children with autism spectrum disorders who received technology-based interventions was significantly different from zero and approached the medium magnitude, d = 0.47 (confidence interval: 0.08-0.86). The influence of age and IQ was not significant. Differences in training procedures are discussed in the light of the negative correlation that was found between the intervention durations and the studies' effect sizes. The results of this meta-analysis provide support for the continuing development, evaluation, and clinical usage of technology-based intervention for individuals with autism spectrum disorders.

The social validity of Social Stories™ for supporting the behavioural and communicative functioning of children with autism spectrum disorder

This study examines the social validity of a family-centred collaborative approach to developing Social Stories™ to support the behavioural and communicative functioning of children with autism spectrum disorder (ASD). Twenty children with Pervasive Developmental Disorder (PDD)/Autism, PDD-Not Otherwise Specified, or Asperger's Disorder (aged 4-12 years) participated in a multiple baseline design across behaviours with a 6-week follow-up. The effects of behaviour stories (to reduce problem behaviours) and communication stories (to facilitate communication) as assessed by parental subjective perceptions of child functioning were evaluated and compared. Using daily parental ratings, behaviour stories were deemed effective for 11 of 17 stories (64.7%), whereas communication stories were deemed effective for 10 of 19 stories (52.6%), with great variability in effect size for both. Results also indicated variability in performance across specific story targets, although parents' perceived effects of Social Stories™ were not linked to any known child characteristics. This study argues that intervention using Social Stories™ to address behavioural and communicative functioning can yield socially valid outcomes across a range of child characteristics and intervention targets. Implications for clinical practice and how present methodological limitations can be addressed in future research are considered.

Using Video Social Stories™ to Increase Task Engagement for Middle School Students With Autism Spectrum Disorders

Four middle school students with autism spectrum disorders participated in a brief functional analysis and a video Social Stories™ intervention to remediate attention-seeking and task-avoidance behaviors. Results indicated that matching video Social Stories™ to specific functions of behaviors increased task-engagement behaviors in the general education classroom for all students. In addition, special and general education teachers, as well as participating students, reported favorable social acceptability of the intervention.

Peer interaction patterns among adolescents with autistic spectrum disorders (ASDs) in mainstream school settings

The aim of the current study was to document the peer interaction patterns of students with autistic spectrum disorders in mainstream settings. Structured observations of a group of 38 adolescents with ASD drawn from 12 mainstream secondary schools were conducted over a two-day period and data compared with those of school, age, and gender matched comparison groups of 35 adolescents with dyslexia and 38 with no identified special educational needs (the ASD and dyslexia groups were also matched on SEN provision). Frequency and duration of peer interaction behaviours were coded. In terms of duration, multivariate analyses of variance (MANOVAs) indicated that participants with ASD spent more time engaged in solitary behaviours, less time engaged in co-operative interaction with peers, and more time engaging in reactive aggression towards peers than either comparison group. In terms of frequency, similar patterns emerged, but additionally participants with ASD engaged in fewer instances of rough/vigorous play, and were subject to more instances of social initiation and instrumental verbal aggression by peers than either comparison group. The findings of the current study support the authors’ theoretical model of peer group interaction processes for individuals with ASD, and have implications for both social skills training and the development of peer awareness and sensitivity. Limitations are noted.

Social Stories™ to improve social skills in children with autism spectrum disorder

Over the past 20 years a variety of treatments have been developed to remediate deficits associated with autism. Since the early 1990s, Social Stories™ have been suggested to positively affect the social development of children with autism spectrum disorder (ASD). Despite much research, there remains uncertainty regarding the effectiveness of this modality. We conducted a systematic review of the literature using pre-defined, rigorous methods. Studies were considered eligible if they were controlled trials evaluating Social Stories™ among persons with ASD. Two reviewers independently screened articles for inclusion, applied eligibility criteria, extracted data, and assessed methodological quality. A qualitative analysis was conducted on six eligible controlled trials. Five of the six trials showed statistically significant benefits for a variety of outcomes related to social interaction. This review underscores the need for further rigorous research and highlights some outstanding questions regarding maintenance and generalization of the benefits of Social Stories™.

Brief report: Increasing verbal greeting initiations for a student with autism via a Social Story™ intervention

Social Stories™ are a common intervention for addressing the social skills deficits individuals with autism often demonstrate. In this study, a Social Story intervention was used to increase acceptable verbal greeting initiations with an 11-year-old boy who had a diagnosis of high functioning autism. A withdrawal design with a comparison condition examined the frequency of acceptable verbal greeting initiations during 5 min observation periods. Results showed no acceptable verbal greeting initiations during both baseline conditions, increased frequency of acceptable verbal greeting initiations during both intervention conditions, and maintenance of intervention levels of behavior with visual supports during the comparison condition.

Social and Communicative Interventions and Transition Outcomes for Youth with Disabilities

The relationship between social and communicative interventions and transition-related outcomes for secondary-aged youth with disabilities is explored in this systematic review. In all, 30 studies intervening with 316 youth with a broad range of disability labels (both high- and low-incidence disabilities) were reviewed. Subgroup analyses were conducted on original research in these areas: augmentative and alternative communication (AAC), conversation skills, decreasing aberrant behavior, and social skills training (SST). Little support was found for AAC and modest support for interventions designed to increase conversation skill acquisition and for SST, and the research in decreasing aberrant behavior was unable to be synthesized because of effect size calculation formula problems. Results are discussed in terms of alignment with extant literature reviews, methodological issues in meta-analysis, recommendations for further research, and practical implications.

Systematic reviews of psychosocial interventions for autism: an umbrella review

AIM

A wide range of psychosocial interventions for the treatment of individuals with autism-spectrum disorders (ASDs) have been evaluated in systematic reviews. We conducted an umbrella review of systematic reviews of the effectiveness of psychosocial interventions for ASD.

METHOD

Comprehensive searches were conducted in 25 bibliographic databases, relevant journals and reference lists up to May 2007. Studies included were systematic reviews on any psychosocial intervention for individuals with ASDs. Two reviewers independently assessed study relevance and quality.

RESULTS

Thirty systematic reviews were included. The majority of reviews evaluated interventions based on behavioural theory (n=9) or communication-focused (n=7) therapies. Positive intervention outcomes were reported in the majority of the reviews. Methodological quality of the reviews was generally poor.

INTERPRETATION

The reviews reported positive outcomes for many of the interventions, suggesting that some form of treatment is favourable over no treatment. However, there is little evidence for the relative effectiveness of these treatment options. Many of the systematic reviews had methodological weaknesses that make them vulnerable to bias. There is a need for further systematic reviews that adhere to strict scientific methods and for primary studies that make direct comparisons between different treatment options.

Behavioural and developmental interventions for autism spectrum disorder: a clinical systematic review

BACKGROUND

Much controversy exists regarding the clinical efficacy of behavioural and developmental interventions for improving the core symptoms of autism spectrum disorders (ASD). We conducted a systematic review to summarize the evidence on the effectiveness of behavioural and developmental interventions for ASD.

METHODS AND FINDINGS

Comprehensive searches were conducted in 22 electronic databases through May 2007. Further information was obtained through hand searching journals, searching reference lists, databases of theses and dissertations, and contacting experts in the field. Experimental and observational analytic studies were included if they were written in English and reported the efficacy of any behavioural or developmental intervention for individuals with ASD. Two independent reviewers made the final study selection, extracted data, and reached consensus on study quality. Results were summarized descriptively and, where possible, meta-analyses of the study results were conducted. One-hundred-and-one studies at predominantly high risk of bias that reported inconsistent results across various interventions were included in the review. Meta-analyses of three controlled clinical trials showed that Lovaas treatment was superior to special education on measures of adaptive behaviour, communication and interaction, comprehensive language, daily living skills, expressive language, overall intellectual functioning and socialization. High-intensity Lovaas was superior to low-intensity Lovaas on measures of intellectual functioning in two retrospective cohort studies. Pooling the results of two randomized controlled trials favoured developmental approaches based on initiative interaction compared to contingency interaction in the amount of time spent in stereotyped behaviours and distal social behaviour, but the effect sizes were not clinically significant. No statistically significant differences were found for: Lovaas versus special education for non-verbal intellectual functioning; Lovaas versus Developmental Individual-difference relationship-based intervention for communication skills; computer assisted instruction versus no treatment for facial expression recognition; and TEACCH versus standard care for imitation skills and eye-hand integration.

CONCLUSIONS

While this review suggests that Lovaas may improve some core symptoms of ASD compared to special education, these findings are based on pooling of a few, methodologically weak studies with few participants and relatively short-term follow-up. As no definitive behavioural or developmental intervention improves all symptoms for all individuals with ASD, it is recommended that clinical management be guided by individual needs and availability of resources.

Social stories: mechanisms of effectiveness in increasing game play skills in children diagnosed with autism spectrum disorder using a pretest posttest repeated measures randomized control group design

An increasing body of literature has indicated that social stories are an effective way to teach individuals diagnosed with autism appropriate social behavior. This study compared two formats of a social story targeting the improvement of social skills during game play using a pretest posttest repeated measures randomized control group design. A total of 45 children diagnosed with Autism Spectrum Disorder (ASD) ages 7-14 were randomly assigned to standard, directive, or control story conditions. Results demonstrated that the standard and directive story formats were equally as effective in eliciting, generalizing and maintaining the targeted social skills in participants who had prior game play experience and Verbal Comprehension Index (VCI) scores from the WISC-IV intelligence test in the borderline range or above.