Using social stories to improve the social behavior of children with Asperger syndrome.

Abstract: To date, the empirical support for the use of social story interventions for children with Asperger syndrome (AS) is small. The purpose of this study was to examine the effects of individualized social story interventions on the social behavior of three children with AS. Using a multiple-baseline-across-participants design, social stories were implemented, and direct observations of the participants' identified target behaviors were conducted three times per week during unstructured school activities (e.g., recess). Data revealed an increase in the social behavior of two of the three participants when the treatment was implemented. Unfortunately, maintenance of target behaviors was not observed. These data provide some initial support for the use of social stories to teach social skills to children diagnosed with AS. However, failure to demonstrate skill maintenance and poor results for one participant highlight possible limitations of the social story intervention and suggest a strong need for further research. Recommendations for future research endeavors and the potential benefits of social story interventions are discussed.

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Asperger syndrome (AS) is a relatively new category in autism spectrum disorders (ASD) that has come into more general use during the last 20 years, despite its shared history with autism. Currently, AS is a term used to describe the mildest and highest functioning end of ASD (Atwood, 1998). Similar to autism, AS is characterized by sustained impairments in the use of social skills necessary for meaningful social interactions, as well as the development of a range of restricted behaviors, activities, and asocial interests that dominate the child's life (Volkmar & Klin, 2000). Despite such impairments, children with AS show no obvious delays in cognitive or language development, have generally good prognoses, and often display interests in the social world (Safran, 2001; Volkmar & Klin, 2000; Wing, 2000). Notably, these characteristics are not typically observed in children with autism.

Although students with AS express interest in the social world, their lack of social skills creates lifelong challenges when interacting and communicating with peers and adults (Church, Alisanski, & Amanullah, 2000). Individuals with AS may perserverate on their topic of interest (e.g., Harry Potter, lawnmowers, dinosaurs) and offer detailed and highly specific, fact-based monologues with little awareness of whether the listener is interested (Myles & Simpson, 1998). This lack of social reciprocity and inability to interpret the listener's verbal and nonverbal social cues results in individuals' perceiving the child with AS as self-absorbed and lacking empathy. Furthermore, children with AS may not understand the unwritten rules of social conduct and engage in inappropriate behaviors (e.g., blurting out socially inappropriate comments). These characteristics distance the child with AS from the social world. Such inappropriate social skills and obsessive interests in obscure subjects may cause children with AS to be victims of continued ridicule and further alienation, despite their attempts at friendship (Moore, 2002; Myles & Simpson, 1998; Williams, 1995). Such ridicule, combined with the lack of social skills necessary to interact with other students, may cause children with AS to be easily stressed and emotionally vulnerable during school and throughout life.

Compounding their social interaction difficulties, children with AS are often misunderstood by educators because of their elevated verbal and cognitive skills and average to above-average academic ability. In fact, educators often describe students with AS as "normal" or "typical" but with odd and/or eccentric social behaviors (Volkmar & Klin, 2000). Too often, educators view such atypical social behaviors as intentional or as evidence of a lack of impulse control (Safran, 2001), rather than as an absence of the skills necessary to understand social phenomena and engage in appropriate interpersonal social interactions (Volkmar, Klin, Schultz, Rubin, & Bronen, 2000). As a result, educators may employ punitive actions rather than specific interventions to teach socially appropriate skills to children with AS.

Over the past several years, the number of children and youth identified as having AS has increased substantially. In a recent report, Hyman, Rodier, and Davidson (2001) suggested prevalence rates for AS to be as high as 63 per 10,000 births. Other age-specific prevalence studies have estimated the prevalence of AS as ranging from 8.4 per 10,000 in preschool children (Chakrabarti & Fombonne, 2001) to 71 per 10,000 in children ages 7 to 16 (Ehlers & Gillberg, 1993). Safran (2001) reported that such prevalence rates appear to be "several times higher than classic Kanner childhood autism, [and suggest] a large unserved student population in North America" (p. 151). Related to this, state departments of education have reported increases in the number of students with AS (National Research Council, 2001). Such increases are likely to lead to significant increases in referrals for special education services. With this in mind, developing and implementing effective programming for children with AS becomes an auspicious challenge for special education.

The most appropriate method for incorporating social skills training for children with AS has received little research attention. Although there is a growing body of research on interventions for higher-functioning individuals with autism, few studies have systematically addressed the efficacy of social skills interventions with purely AS samples. This presents a challenge for assisting students with AS in schools, given recent policy shifts presented in the Individuals with Disabilities Education Act in 1997 (IDEA, 1997) and its current reauthorization in 2004 (IDEA, 2004). Both versions of the law emphasize the use of evidence-based practices based on rigorous scientific research for students with disabilities.

The critical recent information on AS, along with noted policy changes, make it now necessary to evaluate educational interventions with samples of children with AS. As the number of children identified with AS continues to rise, it is imperative that educators and other educational service personnel be mindful of interventions that will benefit these children with cognitive strengths but severe social weaknesses.

Social Stories

A relatively recent intervention recommended for children with AS is the use of social stories. Social stories are brief, individualized short stories that describe a social situation and provide specific behavioral response cues (e.g., appropriate social responses within a defined context) through visual supports and text (Gray, 1998). A social story provides instruction regarding the who, what, when, where, and why of a social situation (Atwood, 1998; Gray, 1998; Gray & Garrand, 1993; Lorimer, Simpson, Myles, & Ganz, 2002). For example, a social story might be written for a child who has difficulty playing fairly. In the story, the setting, target child, and perspectives of the target child in that particular setting are described (e.g., "When I get to the playground, I like to play football. There are other kids who like to play football with me, too"). In addition, the story would include direct information of what playing fairly looks like (e.g., "A good sport would never yell at anybody while playing football during recess. That hurts others' feelings"). Thus, a social story helps ensure a child's accurate understanding of social information for a given setting (Gray, 1998) and provides "how-to" instruction for initiating, responding to, and maintaining appropriate social interactions (Sansosti, Powell-Smith, & Kincaid, 2004).

To date, research on the relative effectiveness of social story interventions used with children with ASD is scant. Prior research has investigated the effects of social story interventions on greeting people appropriately and sharing toys (Swaggart, et al., 1995), reducing tantrum behaviors (Kuttler, Myles, & Carlson, 1998; Lorimer, Simpson, Myles, & Ganz, 2002), improving positive social interactions during lunch (Norris & Dattilo, 1999), decreasing disruptive classroom behaviors (Scattone, Wilczynski, Edwards, & Rabian, 2002), increasing hand-washing and on-task behavior (Hagiwara & Myles, 1999), increasing the frequency of social communication behaviors (e.g., securing attention, initiating requests; Thiemann & Goldstein, 2001), and increasing appropriate play (Barry & Burlew, 2004). In each of these studies, positive trends in data were observed. However, in all of these studies, the participant(s) carried a primary diagnosis of autism, and in most of these studies the goal of the intervention was to increase prosocial behaviors (e.g., social awareness, positive social integration skills) by eliminating pervasive problem behaviors (e.g., tantrum behaviors, spitting, yelling).

The empirical support for social story interventions is limited, but promising. However, with increased emphasis on evidence-based practice, more rigorous research is necessary so that educational personnel can be confident when choosing social stories as possible interventions for children with AS (Sansosti, Powell-Smith, & Kincaid, 2004). Significantly, no published research exists regarding the effects of social story interventions for children with AS specifically. However, social stories seem to be an effective approach for individuals with AS …