School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT)
WORKSHEET
Focused Question:
Do Social Stories reduce inappropriate behavior and increase appropriate behavior for
children under the age of 14 years old with Autism Spectrum Disorder (ASD)?
Prepared By:
Alicia Ellingson, OTS & Megan Lawrence, OTS
Department of Occupational Therapy
Touro University Nevada
874 American Pacific Dr.
Henderson, NV 89014
Date Review Completed:
October 12, 2014
Clinical Scenario:
Autism Spectrum Disorder (ASD) is a disorder that is often associated with disturbances
in communication, social interaction, behaviors, and sensory and perceptual processing
(Thompson & Johnston, 2013). The incidence of ASD within the US is estimated to be
1/66 individuals and is reported to occur in all racial, socioeconomic, and ethnic groups
(Centers for Disease Control and Prevention [CDC], 2012). The behavioral and sensory
challenges often associated with children with ASD can lead to difficulties within the
educational setting. In addition to educational difficulties, children with ASD often
struggle with social interactions with peers and teachers within the school setting (Delano
& Snell, 2006).
Within the educational setting, children with ASD often receive therapeutic services
including occupational therapy (OT). OT practitioners work in collaboration with the
school team to assist the students in social participation and academic performance

throughout the school day. Skilled OT practitioners facilitate students with ASD access to
the educational curriculum to fulfill their role as students by providing supports,
designing interventions, and training other school team members (American Occupational
Therapy Association [AOTA], 2009).
The utilization of social stories for children with ASD is an increasingly popular
intervention designed to assist in the understanding of social situations and then formulate
an appropriate response (Thompson & Johnston, 2013). Social stories are individualized
stories created specifically to describe a certain social situation, person, skill, or concept.
Initially written for children with high-functioning ASD, social stories currently are being
used for children with higher level disabilities as well (Schneider & Goldstein, 2010).
Despite an increase in use of social stories in practice, limited research exists on the
efficacy of social stories as an intervention (Crozier & Tincani, 2007). This illustrates the
need for further research to be completed in order to deem social stories as an effective
intervention to increase appropriate behavior for children with ASD.

Summary of Key Findings:

Summary of Levels I, II and III:

Social stories were found to be effective for children with ASD in

a study comparing an experimental and control group. Targeted
behaviors were observed and increased self-management
behaviors amongst the experimental group (Lal & Ganeson, 2011,
Level III)
The intervention using social stories to improve initiating
conversations, seeking attention, initiating requests, and making
contingent responses utilized alongside a training peer within the
same grade found that the use of social stories may be effective in
increasing the duration of appropriate social engagement for
children with ASD (Delano & Snell, 2006, Level III).
Evidence supports the utilization social stories in conjunction with
sensory integrative-based strategies. Results suggest that the
intervention was successful in increasing desired behavior of the
children with ASD that participated (Thompson & Johnston,
2013, Level III).
Applied behavioral analysis (ABA) is a technique commonly used

with children with ASD. When used in combination with social

story interventions, behavior management and regulation was
improved for children with ASD (Kuoch & Mirenda, 2003, Level
III; Crozier & Tincani, 2010, Level III).
Video modeling combined with social stories was found to
increase the incidence of smiling, conversation initiation, and eye
contact of children with ASD (Scattone, 2008, Level III).
Reading social stories were effective at managing behaviors of
children with ASD (Soenksen & Alper, 2006, Level III; Schneider
& Goldstein, 2010, Level III).
Summary of Level IV and V:
None included in review.
Contributions of Qualitative Studies:
None included in review.

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
Children with ASD often have difficulty within an educational setting, most often due to a
lack of prosocial behavior (Crozier & Tincani, 2010, Level III). To increase appropriate
behavior, OT practitioners often use social stories as a component of their interventions.
However, research into the efficacy of social stories has been limited due to a variety of
reasons including; small sample sizes, limited generalizability, and lack of a control group
for comparison. From the limited research, it has been found that social stories can have a
modest effect within on-task behavior for children with ASD. From this, the clinical and
community-based implications are that social stories can be a tool for teachers and OT
practitioners to utilize within the educational setting to facilitate on-task and appropriate
behavior for children with ASD (Schneider & Goldstein, 2010, Level III). However,
further research needs to be conducted to evaluate the efficacy of the utilization of social
stories as the main intervention for children with ASD to increase appropriate behavior
within an educational setting.
Program development:
Due to the limited research on the efficacy of social stories, more research needs to be
conducted to investigate the generalizability and effectiveness of social stories in
increasing appropriate behavior for children with ASD prior to program development.
Currently, it cannot be determined if social stories should be applied as a main

intervention or only as a component of the overall intervention (Delano & Snell, 2006,
Level III). While the majority of studies on social stories found in increase in appropriate
behavior post-intervention, the limitations within the studies further the importance of the
need for additional research.
Societal needs:
Finding an effective intervention that meets the needs of increasing social skills and
appropriate behavior in children with ASD is extremely important, as the number of
children diagnosed with ASD continues to rise. Children with ASD often have difficulty
with communication and other appropriate behaviors, which is especially noticed within
the classroom setting. This results in a great societal need for interventions that increase
appropriate behaviors for children with ASD, creating more opportunities for their
success within an educational and social setting (Thompson & Johnston, 2013, Level III).
This illustrates the importance of evaluating the efficacy of using social stories as an
intervention to allow OT practitioners the ability to provide evidence based effective
treatments.
Healthcare delivery and policy:
Strong, high-level evidence is needed to establish healthcare policies. Without such, the efficacy
of specific interventions that occupational therapists use is limited. Further evidence is required

before health care delivery and/or policy is can be shaped by the use of social stories due
to the small sample size within existing research and lack of generalizability of the
participants (Kuoch & Mirenda, 2003, Level III).
Education and training of OT students:

It is important for OT students to have knowledge about the potential utilization of social
stories for children with ASD. While more research is needed, social stories could be used
as a part of an intervention to increase appropriate behaviors. OT students would benefit
from education on more interventions for children with ASD, as this is a common
diagnosis treated by OTs and can overwhelm a novice student. Certain protocols have
been found to be effective including creating social storied based off of Dr. Grays format
and allowing the child with ASD to read the stories themselves, or have it read to them
(Soenksen & Alper, 2006, Level III). Such protocols need to be included in training of
OT students.

Refinement, revision, and advancement of factual knowledge or theory:

Further research should be completed in order to deem social stories as an effective

intervention for children with ASD. Research needs to be completed on larger sample
sizes, needs to include comparison groups, and be completed within additional
environments to ensure the effectiveness and generalizability (Soenksen & Alper, 2006,
Level III). Factual knowledge and theories should be not established until stronger

research is published.

Review Process:
Procedures for the selection and critical appraisal of research articles:
Focus question was identified
Inclusion/exclusion criteria identified
Searched terms for appropriate population, intervention, and outcome
Multiple databases were utilized for search
Abstracts were reviewed for inclusion/exclusion criteria
Full-text articles were reviewed
Articles that did not meet criteria were eliminated
Articles that met inclusion criteria were selected for further review
Eight articles were evaluated using the McMaster University critical review forms
Procedures for the Selection and Appraisal of Articles:
Inclusion Criteria:

Adolescents with ASD ages 14 years old and younger

Articles published within last 11 years
English language
Full text research article
Exclusion Criteria:

Adolescents not diagnosed with ASD

Articles published over 11 years ago
Articles not printed within the English language
Not full text article
Gray literature

Search Strategies:
Categories

Key Search Terms

Patient/Client Population

(Autism Spectrum Disorder, young children) &

(Autism, children)

Intervention

(Social stories)

Outcomes

(Behavior regulation), (positive behavior, reduced

negative behavior), & (behavior management)

Databases and Sites Searched

Academic Search Complete, PsychINFO, CINAHL, EBSCO
Quality Control/Peer Review Process:
PIO question was consulted on and approved by course instructor.
Database search completed incorporating population, intervention, and outcome of
the focus question.
Full-text articles were selected in comprehensive literature search.
Articles reviewed by both students for inclusion/exclusion criteria.
Articles that did not meet inclusion/exclusion criteria were eliminated.
Articles were reviewed utilizing McMaster University critical review forms.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence

Study Design/Methodology of Selected Articles

Number of
Articles Selected

Systematic reviews, meta-analysis, randomized

controlled trials

II

Two groups, non-randomized (e.g., cohort, casecontrol)

III

One group, nonrandomized (e.g., before and after,

pretest and posttest)

IV

Descriptive studies that include analysis of

outcomes (single-subject design, case series)

Case reports and expert opinion that include

narrative literature reviews and consensus
statements

Other

0
8
TOTAL:

Limitations of the Studies Appraised:

Levels I, II, and III
Small sample size (Crozier & Tincani, 2010; Delano & Snell, 2006; Kuoch
& Mirenda, 2003; Scattone, 2008; Schneider & Goldstein, 2010;
Soenksen & Alper, 2006; Thompson & Johnston, 2013).
Lack of control group for comparison (Crozier & Tincani, 2010; Delano &
Snell, 2006; Kuoch & Mirenda, 2003; Scattone, 2008; Schneider &
Goldstein, 2010; Thompson & Johnston, 2013).
Language bias (Crozier & Tincani, 2010; Delano & Snell, 2006; Kuoch &
Mirenda, 2003; Lal & Ganeson, 2011; Scattone, 2008; Schneider &
Goldstein, 2010; Thompson & Johnston, 2013).
Lack of generalizability to other students with ASD and other behaviors
(Delano & Snell, 2006; Soenksen & Alper, 2006; Thompson & Johnston,
2013).
Convenience sampling utilized (Crozier & Tincani, 2010; Delano & Snell,
2006; Kuoch & Mirenda, 2003; Scattone, 2008; Schneider & Goldstein,
2010; Soenksen & Alper, 2006; Thompson & Johnston, 2013).
Performance Bias (Crozier & Tincani, 2010; Delano & Snell, 2006; Kuoch
& Mirenda, 2003; Thompson & Johnston, 2013).

Levels IV and V
None included in review.
Other
None included in review.

Articles Selected for Appraisal:

Crozier, S., & Tincani, M. (2010). Effects of social stories on prosocial behavior of preschool
children with Autism Spectrum Disorders. Journal of Autism and Developmental Disorders,
37(9), 1803-1814. doi: 10.1007/s10803-006-0315-7

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), 2942. Retrieved from http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=6582a3aefc4e-4dcf-a2bd-218276796bc8%40sessionmgr111&vid=15&hid=126

Kuoch, H., & Mirenda, P. (2003). Social story interventions for young children with Autism
Spectrum Disorders. Focus on Autism and Other Developmental Disabilities, 18(4), 219227. Retrieved from http://foa.sagepub.com/content/18/4/219.full.pdf+html

Lal, R., & Ganesan, K. (2011). Children with Autism Spectrum Disorders: Social stories and selfmanagement of behavior. British Journal of Educational Research, 1(1), 36-48.
Retrieved from
http://www.sciencedomain.org/abstract.php?iid=80&id=17&aid=213#.VCxtRfldWSo

Scattone, D. (2008). Enhancing the conversation skills of a boy with Aspergers Disorder through
social stories and video modeling. Journal Of Autism & Developmental Disorders, 38(2),
395-400. doi:10.1007/s10803-007-0392-2

Schneider, N., & Goldstein, H. (2010). Using social stories and visual schedules to improve
socially appropriate behaviors in children with Autism. Journal of Positive Behavior
Interventions, 12(3), 149-160. doi: 10.1177/1098300709334198

Soenksen, D., & Alper, S. (2006). Teaching a young child to appropriately gain attention of peers
using a social story intervention. Focus On Autism And Other Developmental Disabilities,
21(1), 36-44. doi:10.1177/10883576060210010501

Thompson, R., & Johnston, S. (2013). Use of social stories to improve self-regulation in children
with Autism Spectrum Disorders. Physical and Occupational Therapy in Pediatrics, 33(3),
271-284. doi: 10.3109/01942638.768322

Other References:
American Occupational Therapy Association. (2009). Tips for educators. Retrieved from
http://www.aota.org//media/Corporate/Files/AboutOT/consumers/Youth/Autism/Autism
%20Teacher%20Tip%20Sheet.pdf

Centers for Disease Control and Prevention. (2012). Prevalence of Autism Spectrum Disorders,
Autism and Developmental Disabilities monitoring network. Retrieved from
http://www.cdc.gov/ncbddd/autism/data.html