A Critical Review of Social Narratives

Purpose: Story-based interventions have been used to address the social, communicative, and behavioral impairments that are characteristic of autism spectrum disorder (ASD). However, no studies have examined the potential benefit of including a typically developing child, such as a sibling, in this type of intervention. Method: This case study examined the social validity of using comic strip conversations (CSCs) for a 6year-old boy with Asperger syndrome and his typically developing younger brother to address conflict in a home setting. The 2 boys received separate adultmediated CSC sessions around several discrete events involving the common theme of sibling conflict. Quantitative subjective ratings of behavior change action and social communication and the presence of restrictive or repetitive behaviors, interests, and activities (American Psychiatric Association [APA], 2013). A universal feature of ASD involves challenges in theory of mind (ToM), which can be thought of as the ability to read and accurately interpret the thoughts and feelings of the self and others (Kuoch & Mirenda, 2003). Many researchers have argued that ToM deficits represent the core cause of the aforementioned triad of ASD impairments (e.g., Baron-Cohen, 1995; Baron-Cohen, Leslie, & Frith, 1985). One popular approach to support ToM development makes use of a class of story-based interventions, including social stories (Gray, 2010; Gray & Garand, 1993) and comic strip conversations (CSCs; were collected in the form of maternal daily diaries. Results: Tau-U analyses across A (baseline), B (CSC with child with ASD only), A (withdrawal), C (CSCs with both the child with ASD and the typical sibling), and A (withdrawal) phases of study indicated therapeutic changes in the child with ASD during Phase C that were maintained in the final withdrawal period. Dyad-specific experiences between siblings and the importance of adult mediation to triangulate shared meaning-making, promote social learning, and address sibling conflict are discussed. Limitations and directions for future research are also considered.

This article describes a family-centered collaborative approach to the development and socially valid assessment of Social Stories™ and comic strip conversations (CSCs) for supporting the social behaviors in children with autism spectrum disorder (ASD). Seventeen children with ASD (ages 4–12 years) participated in either an immediate or a wait-intervention control group. Parents’ perceptions of the effects of Social Stories™ and CSCs to promote more appropriate social behaviors were compared across baseline, intervention, and withdrawal phases of study. Visual analyses of subjective ratings indicated that the intervention was effective for 13 of 17 children (i.e., for 76.5% of cases). Perceived effects of treatment were linked only to the variable of verbal mental age with a minimum age of 3 years predicting success. The authors argue that Social Stories™ and CSCs lead to socially valid outcomes. Although there are exceptions, they are most likely to be effective for addressing social behaviors in the context of interpersonal conflicts when children demonstrate a minimum verbal age of 3 years. Implications, limitations, and directions for future research are discussed.

Amelioration of Aggression and Echolalia With Propranolol in Autism Spectrum Disorder

Social narratives (e.g., Social Stories™) are common antecedent-based interventions promoted for the purposes of improving prosocial behaviors and reducing challenging behavior for children with and without disabilities. Although they are commonly prescribed and used, their effectiveness has almost exclusively been assessed for children with autism spectrum disorder (ASD). The purpose of this review was to synthesize the literature on social narrative interventions for children without ASD using a new synthesis framework: the Single Case Analysis and Review Framework (SCARF). Specifically, the review assessed the quality, rigor, and outcomes of single case design studies measuring the effectiveness of social narratives for decreasing challenging behavior or increasing prosocial behavior in children without ASD. Conclusions suggest cautious use of social narratives in isolation for children without ASD due to variable outcomes and absence of a sufficient number of rigorous studies. Future high-quality research is needed to address questions surrounding effective instructional components, participant characteristics, and implementation fidelity.

Very little is documented regarding the efficacy of social stories and comic strip conversations for promoting an understanding of social situations and the appropriate social behaviors of individuals with autism spectrum disorder (ASD). In addition, few studies on the efficacy of social stories have examined whether outcomes are socially valid. The purpose of this article is to respond to some of the gaps in the literature on the efficacy of a frequently used intervention for children with ASD and to describe a family-centered collaborative approach to developing social stories and comic strip conversations. The results of intervention employing an A-B design are reported for two case vignettes. Clinical implications, limitations of the available data, and potential factors contributing to outcome variability are discussed.

Introduction Autism spectrum disorders (ASD), which include autism, Asperger's Syndrome (AS), and pervasive developmental disorder-not otherwise specified (PDD-NOS), are a group of disorders characterized by a host of difficulties with social interactions, communication, and repetitive behaviors or interests (American Psychiatric Association, 2000). Although currently defined by a triad of impairments, difficulties with social relationships and interactions have been one of the hallmarks of autism since its first description (Kanner, 1943) and, more recently, have been suggested to be the defining feature of ASD (Laushey & Heflin, 2000). Across the spectrum, characteristics of the social sequela manifest uniquely, rarely being the same from one individual to the next. In general, children with ASD demonstrate extreme difficulties engaging in even the simplest of social behaviors, such as engaging in appropriate eye contact, initiating and maintaining conversations, listening to or responding to verbal requests, developing and maintaining age-appropriate friendships , and interacting in basic games (Carter, Ornstein-Davis, Volkmar, & Klin, 2005; Dawson et al., 2004). Despite these generalities, some children with ASD may appear to be social in the presence of familiar adults or peers and, at times, socially engaged. However, the majority of children with ASD will demonstrate extreme social difficulty when in the presence of novel people or stimuli (Handleman, 1999). Given such difficulties, efforts to teach children with ASD skills that enhance participation in family, school, and community activities become paramount. Within the past two decades, the number of children identified as having ASD has increased substantially. Traditionally, ASD were considered a low-incidence disability, occurring in only 4 to 6 per 10,000 (or 1 in approximately 1,600) live births (Lotter, 1967). However, the most current estimates from the Centers for Disease Control and Prevention (CDC, 2007) estimate that ASD occurs in 1 in every 150 births, making it the fastest growing developmental disability in the U.S. Such an increase likely has had a direct impact on educators in public schools across the country in relation to demands for educationally related services. In fact, the U.S. Department of Education reports that the number of children receiving services under the autism category of the Individuals with Disabilities Education Act (IDEA) has increased 1,342% between 1993 and 2006 (Fighting Autism, 2008). Moreover, there has been an increasing trend to include students with ASD in general education classrooms (National Research Council, 2001). Examination of data on inclusion relative to each disability category under the IDEA suggests that students with ASD are increasingly served in inclusive settings (Office of Special Education Programs, 2004). While only 4.8% of students with ASD were included in 1990-1991, nearly 29.1% were in general education for 80% or more of their day in 2003-2004. Truly, educating students with ASD in inclusive environments has become a more common practice. Due to the increased number of students with ASD in schools and the push for providing educationally related services within inclusive environments, effective means of planning and implementing social skills interventions are needed. To be effective, interventions targeting social behaviors should capitalize on the visual learning strengths of students with ASD and allow for repeated imitation of targeted social skills or behaviors (National Research Council, 2001). Furthermore, such interventions should be presented in ways that are unobtrusive and can be implemented within natural contexts. Social Stories[TM] One strategy that has emerged as a common practice for teaching social behaviors to individuals with ASD in schools is the use of Social Stories[TM]. Social Stories[TM] are individualized short stories that can be used to assist persons with ASD in interpreting and understanding challenging or confusing social situations (Gray, 1997, 2003). …

You have accessThe ASHA LeaderFeature1 Jan 2012What’s the Story?What does the research say about how best to use social stories to help children with ASDs? Tiffany L. HutchinsPhD Tiffany L. Hutchins Google Scholar More articles by this author , PhD https://doi.org/10.1044/leader.FTR2.17012012.14 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In A universal feature of autism spectrum disorders (ASDs) is disruption in social cognition—the ability to interpret thoughts and feelings of oneself and others. This disruption is related to struggles with behavioral, communicative, and social functioning. A young boy with an ASD might, for example, physically push a peer instead of asking her to step aside. Telling the boy not to push may seem like the default course correction. But a more promising approach may be to target the core social-cognitive deficit through a story that bolsters the boy’s social understanding of the pushing event. Known in the literature as a “social story,” the approach has become one of the most popular ways to address the social-cognitive difficulties characteristic of ASDs (Hess, Morrier, Heflin, & Ivey, 2008; Reynhout & Carter, 2009). What’s less clear, though, is what exactly social stories are and how best to use them. These questions are complicated because guidelines for using social stories have been offered not only by their originator—educational consultant and former teacher Carol Gray (Gray & Garand, 1993)—but by other professionals working with children with ASDs over the last 25 years (Hutchins, in press). For Gray, a Social Story™ “describes a situation, skill, or concept” narrated according to 10 criteria. According to The New Social Stories™ Book, published in 2010, some of these key criteria include the use of: Background research and the collaboration of a team to answer who, what, when, where, why, and how. A patient, reassuring, and descriptive, rather than directive, approach. Language that is literally accurate and meaningful to the child. Careful consideration of formatting choices (e.g., length of story, font style/size, organization of text and illustrations). Specific sentence “types” that describe social information more than they direct audience behavior. A plan for editing, comprehension checks, and story review schedules. When it comes to research, however, most studies have examined social stories (lowercase) that don’t necessarily follow Gray’s 10 criteria or formal definition. Indeed, researchers and practitioners have not adhered to a uniform method of development and implementation, and a number of social-story “myths” have emerged (see sidebar). Despite this variability, the research in this area is substantive enough to provide some empirically supported recommendations for best practice. A Social Story in Action “Jacob needs visual supports to understand the who, what, where, when, how, and why of our culture and how he fits and belongs.” —Mother of a 17-year-old boy diagnosed with pervasive developmental disorder—not otherwise specified, an ASD So what, according to the existing research, goes into developing accurate, meaningful social stories? The following example provides an illustration. Jacob was enrolled in a general education classroom at his local high school and was receiving services from a speech-language pathologist, special educator, case manager, and paraeducator. He loved wind chimes and music and could play a variety of instruments in a truly gifted manner. Previous assessments indicated that Jacob had deficits in auditory comprehension, his verbal expression was limited to two- to five-word sentences, and his areas of strength were reading and writing. One important communication-enhancement goal involved his voice, which was often soft and whispered and trailed into silence. Following an examination that revealed normal structure and function of the larynx, Jacob began voice treatment with a university-based SLP. Jacob worked hard over the course of several weeks to lengthen his sentences and find what he called his “excellent voice,” which was louder and easier to understand. Unfortunately, he failed to generalize gains made in the clinic to other settings. Because we knew that Jacob could produce an “excellent voice,” we decided to develop a social story with some specific objectives. One was to enhance Jacob’s understanding of the social importance of using his “excellent voice.” Another was to recruit the participation of those with whom he had frequent and direct contact. We collaborated with Jacob, Jacob’s mother, and his SLP to learn about the “who, what, when, where, and why” that surrounded the production of his different voices. We used the Motivation Assessment Scale (MAS; Durand & Crimmins, 1992)—a tool designed to help service providers understand the purpose behind behaviors—and our previous observations of Jacob. We drafted a social story titled “Using my Excellent Voice [PDF]” and revised it with input from Jacob’s mother to ensure accuracy of content. We also incorporated vocabulary important for Jacob that reflected his great interest in music (e.g., a “basso profundo voice”). When asked about pictures, Jacob noted that he would like “BoardMaker pictures” in his story so we added Picture Communication Symbols. We incorporated particular font and formatting choices to highlight key messages (for instance, different fonts represent soft and loud voices). We also made specific choices about the length and complexity of sentences and illustrations on each page. We shared hard and electronic copies of the social story with Jacob, Jacob’s mother, and his special education team members. They agreed to read the social story with him across contexts, such as home and various school settings, to facilitate acquisition and generalization of skills. The electronic version of the social story was particularly important for Jacob, who often used an iPod touch; we expected use of this medium to enhance Jacob’s interest in and access to the story. Our team identified a topic—Jacob’s voice—that seemed critical to his success as a communicative partner. Through testing, discussion, and observation, we determined that the target represented an area in which Jacob had demonstrated some competency, which increased the likelihood that it was a developmentally appropriate target. We learned that Jacob was more likely to use his “excellent voice” when others spoke to him using short sentences and gave him more time to respond. Research Basis This example of the development and application of a social story is supported by research. But first, a caveat from descriptive reviews (Ali & Frederickson, 2006; Nichols, Hupp, Jewell, & Ziegler, 2006; Rust & Smith, 2006, 2011; Sansoti, Powell-Smith, & Kincaid, 2004) and quantitative literature reviews (Kokina & Kern, 2010; Reynhout & Carter, 2006, 2011; Test, Richter, Knight, & Spooner, 2010): Most authors agree that social stories are a promising intervention, but they universally acknowledge such methodological limitations as confounding treatment variables, lack of experimental controls, use of weak designs, and lack of research on efficacy, which demands rigorous experimental controls. The conclusions of others have been more positive. For instance, The National Standards Project (National Autism Center, 2010) identifies social story intervention as an established treatment for ASDs for children ages 6–14, based on sufficient quality, quantity, and consistency in the evidence base. Much of that evidence base points to effectiveness of the following practices, used in our work with Jacob: A team approach to gathering information. Although the research contains a few examples of appropriately rich data collection practices (Crozier & Tincani, 2005, 2007; Delano & Snell, 2006; Hutchins & Prelock, 2008; Lorimer, Simpson, Myles, & Ganz, 2002), experience suggests that these aspects are often underdeveloped or entirely overlooked in practice. To understand more fully the cause and purpose of problematic behaviors, social story authors are encouraged to—as done with Jacob—conduct observations and interview relevant others (e.g., parents, teachers, and other involved professionals). Performance of a functional behavioral analysis (FBA). This problem-solving process is designed to identify the purpose of a maladaptive behavior and strategies to address it. In our case, we used observation and the Motivation Assessment Scale to explore the purposes behind Jacob’s behavior. In support of this approach, a recent meta-analysis concluded that studies that used some form of FBA yielded higher effect sizes than those that did not (Kokina & Kern, 2010). Use of comprehension checks. Before formally launching our intervention with Jacob, we introduced the story to him and checked his comprehension of the text and images. Ensuring that key messages in a social story are understood as intended has received empirical support (Kokina & Kern, 2010; Reynhout & Carter, 2006). Use of repetition in teaching of the story. In Jacob’s case, he and all participants agreed to read the social story once or twice a week for several weeks to ensure constant exposure and reinforcement (Hutchins & Prelock, 2008; Norris & Datillo, 1999). The research base is murkier on other aspects of social stories. They’ve been used successfully to address an extraordinarily broad set of intervention targets (Hutchins, in press), including behavioral targets such as tantrums and aggression, communicative targets such as greeting and eye contact, and social interaction targets such as peer engagement and joint attention. In a recent meta-analysis, Kokina and Kern (2010) suggested that social stories targeting the reduction of problem behaviors may be more effective than those that teach appropriate social skills; however, researchers have rarely considered whether and which prerequisite skills or social understandings are needed to achieve social interaction goals (Kokina & Kern, 2010). In fact, from a theoretical perspective, any behavior that would benefit from enhanced social cognition may be an appropriate target of social stories when intervention is responsive to the individual’s developmental level. Social stories have been used successfully with children and adolescents with ASDs who vary widely in their cognitive and linguistic profiles. Gray (Gray & Garand, 1993) suggested early on that social stories were likely to be most effective for individuals with good language skills. Subsequently, Gray (1998) suggested that, with modification, social stories can be used successfully for individuals with ASDs with more severe challenges. However, investigations of the use of social stories in this population are comparatively rare and the evidence so far is mixed (Barry & Burlew, 2004; Quirmbach et al., 2009; Swaggart et al., 1995). A number of questions also persist about the best strategies for developing social stories. Gray (e.g., 1998, 2010) has asserted that sentences in a Social Story™ must be of a particular type and those types must adhere to a specific ratio. Readers familiar with the history of the social story literature will recognize various sentence types (e.g., perspective sentences, control sentences, directive sentences) that have undergone revision over the years. When researchers have systematically examined this issue, however, the usefulness of Gray’s sentence types and ratio has been seriously challenged (see Okada, Ohtake, & Yanagihara, 2008; Quirmbach et al., 2009; Reynhout & Carter, 2006, 2011). One point, however, is clear: What’s critical in the development of a social story is the gathering of accurate and individualized information. Ideally, this process involves collaboration among family members, caregivers, and professionals. The collaborative process we used in Jacob’s case helped us refine our thinking, coordinate workable plans, and develop shared responsibility for supporting his success. Indeed, the increasing popularity of social stories may be explained not only by the positive effects they may have on the audience, but also by their potential benefits to authors (Ali & Fredrickson, 2006). Three Myths About Social Stories Myth: The purpose of a Social Story™ is to change audience behavior. Fact: The purpose of a Social Story™ is to share meaningful and accurate information in a supportive, safe, and positive way. “The theory is that the improvement in behavior that is frequently credited to a Social Story is the result of improved understanding of events and expectations” (Gray, 2010, p. xxxi). Myth: Social Stories™ are quick and easy to develop. Fact: The planning, development, implementation, monitoring, and revision of Social Stories™ can be an incredibly time-intensive procedure. Ideally, it involves gathering accurate information and the participation of a team that has direct contact with the audience. Myth: Social Stories™ focus only on challenging situations. Fact: Gray (2010) has written with emphasis that “50% of all Social Stories must applaud what the audience is doing well. ...The rationale is simple. Given that Social Stories are helpful in teaching new concepts and skills, they may also be just as powerful in adding meaning and detail to praise” (p. xxxv). Sources Ali S., & Fredrickson N. (2006). Investigating the evidence base of Social Stories.Educational Psychology in Practice, 22(4), 355–377. CrossrefGoogle Scholar Barry L. M., & Burlew S. B. (2004). Using social stories to teach choice and play skills to children with autism.Focus on Autism and Other Developmental Disabilities, 19(1), 45–51. Google Scholar Crozier S., & Tincani M. J. (2005). Using a modified social story to decrease disruptive behavior of a child with autism.Focus on Autism and Other Developmental Disabilities, 20(3), 150–157. Google Scholar Crozier S., & Tincani M. J. (2007). Effects of social stories on prosocial behavior of preschool children with autism spectrum disorders.Journal of Autism and Developmental Disorders, 37, 1803–1814. Google Scholar Delano M., & Snell M. E. (2006). The effects of social stories on the social engagement of children with autism.Journal of Positive Behavior Interventions, 8(1), 29–42. Google Scholar Durand V. M., & Crimmins D. B. (1992). The Motivation Assessment Scale (MAS). Topeka, KS: Monaco and Associates. Google Scholar Gray C. (1998). Social stories and comic strip conversations with students with Asperger syndrome and high-functioning autism.In Schopler E. (Ed.), Asperger Syndrome or High Functioning Autism?(pp. 167–194). New York: Plenum Press. Google Scholar Gray C. (2010). The New Social Story™ Book. Arlington, TX: Future Horizons. Google Scholar Gray C., & Garand J. D. (1993). Social stories: Improving responses of students with autism with accurate social information.Focus on Autistic Behavior, 8(1), 1–10. CrossrefGoogle Scholar Hess K. L., Morrier M. J., Heflin L. J., & Ivey M. L. (2008). Autism treatment survey: Services received by children with autism spectrum disorders in public school classrooms.Journal of Autism and Developmental Disorders, 38, 961–971. CrossrefGoogle Scholar Hutchins T. L. (in press). Social Stories™.In Prelock P. A. & McCauley R. J. (Eds.). Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interaction.Baltimore: Brookes. Google Scholar Hutchins T. L., & Prelock P. A. (2008). Supporting theory of mind development: Considerations and recommendations for professionals providing services to individuals with autism spectrum disorder.Topics in Language Disorders, 28(4), 340–364. CrossrefGoogle Scholar Kokina A., & Kern L. (2010). Social Story™ interventions for students with autism spectrum disorders.Journal of Autism and Developmental Disabilities, 40, 812–826. CrossrefGoogle Scholar Lorimer P. A., Simpson R. L., Myles B. S., & Ganz J. B. (2002). The use of social stories as a preventative behavioral intervention in a home setting with a child with autism.Journal of Positive Behavioral Interventions, 4, 53–60. Google Scholar National Autism Center. (2010). National Standards Project. Retrieved from www.nationalautismcenter.org. Google Scholar Nichols S. L., Hupp S. D., Jewell J. D., & Zeigler C. S. (2006). Review of Social StoryTM interventions for children diagnosed with autism spectrum disorders.Journal of Evidence-Based Practices for Schools, 6(1), 90–120. Google Scholar Norris C., & Datillo J. (1999). Evaluating effects of a social story intervention on a young girl with autism.Focus on Autism and Other Developmental Disabilities, 14(3), 180–186. Google Scholar Okada S., Ohtake Y., & Yanagihara M. (2008). Effects of perspective sentences in Social Stories™ on improving the adaptive behaviors of students with autism and related disabilities.Education and Training in Developmental Disabilities, 43(1), 46–60. Google Scholar Quirmbach L. M., Lincoln A. J., Feinberg-Gizzo M. J., Ingersoll B. R., & Andrews S. M. (2009). Social stories: Mechanisms of effectiveness in increasing game play skills in children diagnosed with autism spectrum disorders using a pretest posttest repeated measures randomized control group design.Journal of Autism and Developmental Disorders, 39(2), 299–321. Google Scholar Reynhout G., & Carter M. (2006). Social stories for children with disabilities.Journal of Autism and Developmental Disorders, 36, 445–469. CrossrefGoogle Scholar Reynhout G., & Carter M. (2009). The use of Social stories by teachers and their perceived efficacy.Research on Autism Spectrum Disorders, 3, 232–251. CrossrefGoogle Scholar Reynhout G., & Carter M. (2011). Evaluation of the efficacy of Social Stories™ using three single subject metrics.Research in Autism Spectrum Disorders, 5, 885–900. CrossrefGoogle Scholar Rust J., & Smith A. (2006). How should the effectiveness of Social stories to modify the behavior of children on the autistic spectrum be tested?.Autism, 10(2), 125–138. Google Scholar Sansoti F. J., Powell-Smith K. A., & Kincaid D. (2004). A research synthesis of social story interventions for children diagnosed with autism spectrum disorders.Focus on Autism and Other Developmental Disabilities, 32(6), 535–543. Google Scholar Swaggart B. L., Gagnon E., Bock S. J., Earlies E. L., Quinn C., Myles B. S., & Simpson R. L. (1995). Using social stories to teach social ad behavioral skills to children with autism.Focus on Autistic Behavior, 10, 1–15. Google Scholar Test D. W., Richter S., Knight V., & Spooner F. (2011). A comprehensive review and meta-analysis of the Social StoriesTM literature.Focus on Autism and Other Developmental Disabilities, 26(4), 49–62. doi:10.1177/1088357609351573. Google Scholar Author Notes Tiffany L. Hutchins, PhD, is assistant professor of communications sciences and disorders at the University of Vermont. Her research interests include child language development, measures of Theory of Mind, and the efficacy of social stories to remediate deficits associated with autism. Contact her at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 17Issue 1January 2012 Get Permissions Add to your Mendeley library History Published in print: Jan 1, 2012 Metrics Downloaded 2,059 times Topicsasha-topicsleader_do_tagasha-article-typesCopyright & Permissions© 2012 American Speech-Language-Hearing AssociationLoading ...

SIG 16 Perspectives Vol. 12, No. 3, October 2011

Socially appropriate behavior is required for a child to function successfully in home, recreational, community, and school settings. Students with autism spectrum disorder (ASD) may require specialized interventions focusing on social skill remediation. One such intervention is a social narrative, used to help students with ASD acknowledge other people's feelings, thereby increasing and improving appropriate social interactions with peers. A social narrative uses photographs, written narrative, and other graphics to describe and illustrate a target behavior that is socially appropriate. Social narratives are easy and cost effective to create and can be produced in hard copy or digitally. This article will discuss technology features currently available for creation of a social narrative, benefits of digital social narratives, as well as a “how-to” guide.

The dorsal medial prefrontal cortex and basolateral amygdala exhibit social behavior-relevant neuronal oscillations, representing unified pathophysiological mechanisms underlying social behavioral deficits.

The dorsal medial prefrontal cortex and basolateral amygdala exhibit social behavior-relevant neuronal oscillations, representing unified pathophysiological mechanisms underlying social behavioral deficits.

Personalization of social narratives for students with Autism Spectrum Disorder: Brief experimental analysis

Autism spectrum disorder (ASD) is a developmental disorder that impairs the development of social and communication skills. There is evidence that children with ASD prefer images of self over others [1] . These studies may explain the effectiveness of video self-modeling (VSM), an evidence-based ASD intervention in which one learns by watching oneself on video performing a target behavior. VSM content is difficult to create as target behaviors are sporadic. In this paper, we propose the MEBook system which uses a Kinect sensor to inject self-images into a gesture-based social narrative to teach children with ASD proper greeting behaviors. MEBook consists of two components. The first component is a social narrative. A social narrative is an animated story about the main character meeting and greeting different cartoon characters in a particular setting. Self-modeling is achieved by first replacing the main characters face with an image of the learner, and then animating the learner's body and voice to match the narration. The second component is a positive reinforcement practice session in which the subject is prompted to greet different cartoon characters. Through depth-based body posture tracking, proper greeting behaviors are recognized and immediately reinforced with praise and visual confetti. Novel computational multimedia tools are proposed to turn video recordings of successful attempts into VSM content, thereby alleviating the tedious production process. A multiple-baseline single subject pilot study has been conducted and the preliminary results show that MEBook is potentially effective in teaching greeting behaviors to children with ASD.

The ability to coordinate attention to events or objects between interactive social partners, referred to as social attention, is of great significance for adaptive social behaviors and nonverbal communications in our daily life, helping us to infer other person’s inner state (e.g., intentions, goals) and learn about where important events (e.g., food, danger) occur in the environment. In recent years, many studies have demonstrated that social cues (e.g., eye gaze, head orientation and walking direction of biological motion) can trigger reflexive attentional orienting effects using adapted central cueing paradigm originally designed by Posner. However, not all of us are equally adept at directing attention to where others are focusing on, and this ability is strongly impaired in individuals with autism spectrum disorder (ASD), a highly genetic neurodevelopmental disorder marked by striking social deficits and repetitive behaviors. Here we systematically reviewed recent work on abnormal social attention behaviors and its underlying neural mechanisms in ASD. We first expatiated a typical social attention behaviors indexed by covert and overt attention in ASD. It has been documented that ASD individuals tend to show reduced reflexive orienting effect manifesting itself in both covert attention and overt eye movement compared to typically developing individuals (TD). Yet some controversies concerning the malfunction of social attention in ASD remain to be resolved, based on some evidence demonstrating comparable orienting effect between ASD and TD group. Then we summarized the development course of social attention in ASD. Crucially, atypical orienting to eye gaze is more likely to be observed in younger children but not older children or adults with ASD. It is reasonable to postulate that ASD individuals may acquire this ability through overlearning the association between social cues and targets in everyday life as they grow older. Furthermore, we discussed the neural basis of abnormal social attention behaviors in ASD. Using a combination of psychophysical paradigms and neuroimaging techniques, researchers have reported atypical neural activities in superior temporal gyrus and prefrontal cortex under the supraliminal condition as well as abnormal activation in amygdala under the subliminal condition in the brain of ASD. Moreover, the ASD group showed much less difference in activation of frontoparietal attention networks between social and nonsocial attention task than the TD group, implying disruptive social attention in ASD. Finally, several perspectives on further investigations were put forward given the controversies and insufficient evidence concerning the malfunction of social attention in ASD. Future studies should employ multiple types of social cues (e.g., eye gaze and walking direction of biological motion) in conjunction with more ecological paradigms to investigate conscious and non-conscious social attention behaviors from a developmental approach. More importantly, more neuroimaging studies are needed to explore the functional connections among several key cortical regions and subcortical regions underlying atypical social attention behaviors in ASD. Such efforts will help to facilitate the early diagnosis and intervention of ASD.

You have accessThe ASHA LeaderFeature1 Sep 2008Autism Spectrum Disorders in the SchoolsAssessment, Diagnosis, and Intervention Pose Challenges for SLPs Gail J. RichardPhD, CCC-SLP Gail J. Richard Google Scholar More articles by this author , PhD, CCC-SLP https://doi.org/10.1044/leader.FTR3.13132008.26 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In A challenge for school-based speech-language pathologists is to meet their multiple responsibilities adequately while addressing the unique needs of students with autism spectrum disorders (ASD). This challenge requires that school-based SLPs maintain current knowledge on research and clinical practice recommendations for students with ASD. In February 2007 the Centers for Disease Control and Prevention revised the prevalence figures for ASD to one in every 150 individuals. Once characterized as a “low-incidence disorder,” ASD is now one of the highest-frequency programming challenges in the educational setting. There are several hypotheses for the increased incidence. One contributing factor is an increased awareness of the disorder through the Internet, media coverage of high-profile cases, professional training, and parent support groups and services. A second factor is the ability to diagnose the full spectrum of autism disorders available since 1994, when the diagnostic criteria were modified in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (American Psychiatric Association, 1994) to include Asperger’s syndrome and higher-functioning individuals within ASD. A third factor appears to be an actual increase in the incidence and severity of childhood developmental disorders in general. Screening and Assessment SLPs are often on the front line for preschool screening and intervention. The unusual developmental characteristics associated with ASD are noticed immediately by SLPs evaluating language acquisition patterns and milestones. Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span (ASHA, 2006c) lists multiple assessment tools for professionals to use as part of a multidisciplinary team (see online sidebar for more information on ASHA documents). As ASD has gained a higher profile nationally, disorder labels are being applied at younger ages to qualify for intervention services. Parents concerned about their child’s development typically turn to their pediatrician. However, a study conducted by Dosreis (2006) found that very few pediatricians routinely screen for ASD and most are unfamiliar with screening tools. The pediatricians who reported screening for ASD admitted that the assessment was prompted by parent concerns rather than their own routine practice procedures. In response to escalating concerns, the American Academy of Pediatrics published Caring for Children with Autism Spectrum Disorders: A Resource Toolkit for Clinicians, a pediatric autism screening toolkit for health care professionals. Professionals need to consider the possibility of other developmental disorders that mirror many of the ASD characteristics during the preschool years. There is considerable overlap of characteristics in the profiles of different developmental disorders during the preschool years. The focus should be on identifying developmental areas that have been compromised and need to be addressed in treatment goals. It is important to realize that many of the assessment tools are designed for ASD. By choosing an autism screening checklist or assessment instrument, the professional may have already decided that a child’s developmental behavior pattern indicates ASD. For example, a clinician’s use of the Childhood Autism Rating Scale, Gilliam Autism Rating Scale, Autism Diagnostic Observation Schedule, etc., presume autism and are used to substantiate its severity. Other screening tools that encompass a broader variety of possible developmental disorders, such as Differential Assessment of Autism and other Developmental Disorders (DAADD, Richard & Calvert, 2003), need to be considered. DAADD identifies pertinent childhood behaviors that can be used to discriminate among developmental disorders. Most childhood developmental disorders have common features, that become more distinct over time. With early intervention, some of the characteristics should resolve, while the remaining features allow better differentiation of a developmental disorder. The DAADD includes observation of the developmental areas of language, pragmatic/social, sensory, motor (gross and fine), medical/physical involvement, and behavior. Disorders included for consideration are the autism spectrum (Asperger, autism, Rett, pervasive developmental disorder–not otherwise specified), as well as processing/language-learning disability, mental retardation, and other medical syndromes. The results assist a professional to pursue more specific assessment for possible developmental disorders that are indicated at a 40% level or higher. The DAADD also builds awareness for both parents and professionals regarding the considerable overlap among disability characteristics during the preschool years. Finally, the profile of characteristics of concern in the developmental areas evaluated (i.e., language, social, motor, sensory, physical, behavior) become the target goals for the subsequent treatment plan. The Vineland Adaptive Behavior Scale is another standardized, open-ended interview assessment tool designed to evaluate domains of socialization, communication, motor, and daily living skills (Sparrow, Balla, & Cicchetti, 1984). It is important that the assessment information encompass all developmental aspects, not just speech/language, to develop comprehensive treatment goals. SLPs have a responsibility to help educate parents and other professionals in discriminating features of ASD versus other developmental disorders to arrive at an accurate diagnosis. A Web-based autism video glossary provides more than 100 videoclips that help parents and professionals recognize the early symptoms of autism. Amy Wetherby of Florida State University and Nancy Wiseman of First Signs created this resource. (Users must register but may access the glossary at no charge.) Diagnosis and Intervention Successful treatment is dependent on accurate diagnosis. The ASHA guidelines (ASHA, 2006c) state that the SLP is an independent health care provider with responsibilities in screening, diagnosis, and evaluation of autism. According to the ASHA policy documents, SLPs who acquire and maintain the necessary knowledge and skills can diagnose ASD, typically as part of a diagnostic team. SLPs practicing in public schools need training in the clinical criteria for ASD; they also need to be comfortable with and experienced in using and interpreting reliable, valid ASD diagnostic assessment tools. SLPs working with ASD must be cautious about presuming specific deficits based on a diagnostic label. Every individual within ASD will share basic core characteristics but also will present a unique compilation of the features. Practicing professionals need to understand the neurological aspects in conjunction with the behavioral symptoms to reliably diagnose difficulties and design intervention goals. One particularly challenging differential diagnosis is Asperger’s syndrome versus nonverbal learning disorder (NVLD). Researchers have theorized that 80% of individuals with Asperger’s syndrome also present with characteristics of NVLD, suggesting that these are clinically overlapping disorders related by their neurological site. The fibers that link the cerebellum, basal ganglia, and prefrontal lobes are responsible for inhibitory control over executive functions such as thoughts, attention, and action. Deficits in this area result in too much communication among these areas of the brain, too little inhibition, and a tendency to shut out the rest of the world (Casanova, Buxhoeveden, Switala, & Roy, 2002). Differentiating ASD from NVLD illustrates the importance of ensuring that treatment is consistent with the etiology of ASD, which is biochemical and neurological in origin. Patience and routine are paramount in every intervention plan. The treatment goal should have a functional impact that the person understands. Give the individual time to adjust to the stimuli, don’t overwhelm the individual’s sensory system, and keep data to guide your treatment decisions and progress. Commercial treatment methodologies for ASD are marketed aggressively to parents and school systems. An SLP can help objectively evaluate the variables targeted in a program to make sure they are a match for the individual’s profile (for questions to ask in evaluating programs, products, and procedures, visit the ASHA Web site.). Autism occurs on a continuum of severity and causes. One treatment program will not address all individuals with ASD. If not carefully evaluated, an intervention approach can result in wasted time, energy, and money, or may cause harm to an individual with ASD. Collaboration ASD is a syndrome disorder, implying deficits in multiple developmental areas. The SLP is a critical member of the multidisciplinary team and must work in conjunction with other professionals. Team members must collaborate on goals and ensure consistency across all settings to achieve a functional impact, as treatment that occurs in isolation will not generalize to other settings. Research Empirical research to justify specific treatment approaches is significantly limited because of the multiple behavioral characteristics that are encompassed under the autism spectrum. Genetic analysis of various chromosomes, gender differences, environmental factors, biochemical balance, communication between various neurological structures, and developmental mutations are just a few of the aspects of ASD being evaluated. While the evidence is being built, the professional must stay informed of research studies and carefully integrate findings into clinical practice. Participation in continuing education activities is required to remain current with the most recent advances in ASD. References American Academy of Pediatrics. (2007). Caring for Children with Autism Spectrum Disorders: A Resource Toolkit for Clinicians [CD-ROM]. Available at http://www.aap.org/publiced/autismtoolkit.cfm. Google Scholar American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, Fourth edition. Text revision. Washington, DC: Author. Google Scholar American Speech-Language-Hearing Association. (2006c). Guidelines for speech-language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the lifespan. Available at www.asha.org/policy. Google Scholar American Speech-Language-Hearing Association. (2006). Principles for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span [Technical Report]. Available from www.asha.org/policy. Google Scholar American Speech-Language-Hearing Association. (2006b). Knowledge and skills needed by speech-language pathologists for diagnosis, assessment, and treatment of autism spectrum disorders across the lifespan. Available at www.asha.org/policy. Google Scholar American Speech-Language-Hearing Association. (2006a). Roles and responsibilities of speech-language pathologists in diagnosis, assessment, and treatment of autism spectrum disorders across the lifespan: Position statement. Available at www.asha.org/policy. Google Scholar Casanova M. F., Buxhoeveden D. P., Switala A. E., & Roy E. (2002). Asperger’s syndrome and cortical neuropathology.Journal of Child Neurology, 17, 142–145. CrossrefGoogle Scholar Center for Disease Control and Prevention. (2007). Available at www.cdc.gov/ncbddd/autism. Google Scholar Dosreis S., Weiner C. L., & Lakeshia J. (2006). Autism spectrum disorder screening and management practices among general pediatric providers.Journal of Developmental and Behavioral Pediatrics, 27, S88–S94. CrossrefGoogle Scholar Gilliam J. E. (1995). The Gilliam autism rating scale (GARS). Austin, TX.: Pro-Ed. Google Scholar Lord C., Rutter M., DiLavore P. C., Risi S. (1999). Autism Diagnostic Observation Schedule (ADOS). Los Angeles: Western Psychological Service. Google Scholar Richard G., & Calvert L. (2003). Differential assessment of autism & other developmental disorders (DAADD). East Moline, IL, LinguiSystems. Google Scholar Schopler E., Reichler R. J., & Ro B. (1986). Childhood Autism Rating Scale (CARS). New York, NY: Irvington Publishers. Google Scholar Sparrow S. S., Balla D. A., Cicchetti D. V. (1984). The Vineland adaptive behavior scales. Circle Pines, MN: American Guidance Service. Google Scholar Author Notes Gail J. Richard, PhD, CCC-SLP, chair of the Department of Communication Disorders and Sciences at Eastern Illinois University, can be reached at [email protected]. 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