society & animals (2014) 1-21

brill.com/soan

Interaction with a Therapy Dog Enhances the

Effects of Social Story Method in Autistic Children

Andreea A. Grigore
Research Department of Autism Transilvania Association, Gheorghe
Marinescu, Romania

Alina S. Rusu
Department of Special Education, Faculty of Psychology and Sciences of
Education, Babes-Bolyai University, Cluj-Napoca, Romania
alina.rusu@ubbcluj.ro

Abstract

This study explored the effects of a combination between two methods that have
proved to enhance the social abilities of autistic childrenSocial Story and Animal
Assisted Therapy. The main hypothesis of this investigation was that a naturally
enriched social environment (i.e., the presence of a therapy dog) improves the effective-
ness of Social Story method. Two social skills were targeted: (1) the ability to greet a
social partner and (2) the ability to introduce oneself to a social partner, by using a
standard single-subject research design. Three preschool autistic children were included
in the study. The dependent variables were the frequency of the appropriate social
interactions relevant to the target social skill, the level of prompt needed to provide the
expected social response, and the frequency of social initiations. The presence of the
therapy dog while reading the social story increased the frequency of social initiations
and decreased the level of social prompt needed to elicit social responses from children
with autism.

Keywords

ASD children human-animal interaction Social Story method animal-assisted

activity

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The profound impairment in social abilities is considered the most impor-

tant deficit that individuals with autism spectrum disorders (ASD) experi-
ence across their life span (Nikopoulos & Keenan, 2003; Scattone, 2007). Social
impairment may manifest itself in avoidance of eye contact, difficulties in
social communication, lack of pretend play, and social withdrawal (Scattone,
Tingstrom, & Wilczynski, 2006; Kokina & Kern, 2010). There are indications
that autistic individuals may actually be motivated to interact with others, but
the rules of the social world may be confusing and hardly understandable to
them (Scattone, 2007). Therefore, they usually engage less in social interactions
and initiate or respond to peers initiations less frequently than non-autistic
individuals respond. This may result in negative long-term outcomes affecting
their interpersonal relationships and predisposition to mental health prob-
lems later in life (Howlin, Goode, Hutton, & Rutter, 2004).
Practitioners working with children with ASD agree more and more that
social impairment does not necessarily imply a lack of desire or interest to
interact with others, but rather a lack of necessary social skills to carry out suc-
cessful social interactions (Scattone, 2007). In this light, several types of inter-
ventions have been designed to improve the level of social skills of autistic
individuals. One of the most popular interventions used in special education
in general and in the treatment of autism in particular (i.e., targeting social
skill development in children with ASD) is the Social Story intervention (Gray,
1993). This type of intervention aims at providing autistic individuals with
the social information they lack and thus help them develop the appropriate
behavior in social interactions and interpersonal relationships (Gray, 2000;
Kuoch & Mirenda, 2003).
To meet the defining criteria proposed by Gray (2004), a social story must
contain several types of sentences, in a specific ratio: (a) descriptive sen-
tencesproviding factual information about specific social situations; (b)
perspective sentencesdescribing reactions, thoughts, and feelings of other
people involved in the situation; (c) directive sentencesproviding informa-
tion about the necessary steps needed to carry out a social interaction; (d)
affirmative sentencesenhancing meanings by expressing commonly shared
opinions and values; (e) cooperative sentencesidentifying what others
would do to support the target individual; and (f) control sentenceswritten
by the target individual specifically to identify and recall the information to be
used in a given social situation. Social stories are usually narrated in the first or
the third person point of view. This facilitates the childs identification with the
intended protagonist of the story. In summary, social stories tend to bring ben-
efits to the social life of autistic children due to the following characteristics:

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1. The use of both words and images in coding social information addresses
the visual learning strengths of children with ASD (Travis & Sigman,
1998). By combining visual cues with verbal cues, they help children with
ASD to better understand desirable social behaviors, before they face the
real interpersonal interaction (Crozier & Tincani, 2005).
2. A design is provided at the level of verbal and cognitive comprehension
of each child (Ivey, Helfin, & Alberto, 2004).
3. They address specific strengths and deficits in ASD, such as the imperious
need for predictability, difficulty in acquiring long response chains, and
preference for visual instructions (Kokina & Kern, 2010).

The first step in designing a social story is to identify the target of the inter-
vention (Gray, 2004). This target can be a specific social skill or a more
complex behavior expected in a specific social situation. A child can use
the story as a learning environment and as a tool for understanding and
internalizing appropriate social behavioral elements (Sansosti, Powell-
Smith, & Kincaid, 2004).
To date, there are numerous studies that validate the Social Story method as
an effective behavioral intervention for improving the social abilities of autis-
tic children. Over the last decade, several authors have evaluated the effective-
ness of the Social Story method in decreasing the frequency and the intensity
of several problematic behaviors, such as aggression, screaming, grabbing
toys, and crying (Kuoch & Mirenda, 2003; Crozier & Tincani, 2005). Also, the
effectiveness of this method has been evaluated in increasing the frequency
and intensity of desirable behaviors, such as greeting and sharing things
(Swaggart et al., 1995), choice and playful behavior (Barry & Burlew, 2004), and
other types of social interactions (Scattone, Tingstrom, & Wilczynski, 2006).
In many of these studies, the Social Story method has been used either as a
sole intervention (Scattone, Tingstrom, & Wilczynski, 2006), or combined
with other interventions, such as verbal and pictorial prompts, the reinforce-
ment of appropriate responses, behavior charts, and various priming strategies
(Crozier & Tincani, 2005).
Other interventions that seem to be efficient in improving the social abili-
ties of autistic children are the Animal Assisted Activities (AAA) and Animal
Assisted Therapy (AAT). According to Delta Society (www.deltasociety.
org), AAA include visits by companion animals (i.e., casual meet and greet
events), while AATs are more elaborated, goal-directed interventions, which
are delivered by a health/human service professional with specialized exper-
tise within the scope of practice of his/her profession. Both AAT and AAA can

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improve the physical, social, emotional, and cognitive functioning of several

categories of people, such as children, adolescents, adults, and elderly people
(Chandler, 2005).
Recent data indicate that children with autism can comprehend non-human
animal communication better than human communication (Prothmann,
Ettrich, & Prothmann, 2010). This might indicate that dogs communicate their
intentions on a level that children with ASD find easier to predict and process.
Prothmann, Ettrich, and Prothmann (2010) suggest that the use of all the
elements of the social environment, including domestic animals and complex
naturally occurring stimuli, should be considered when planning therapeutic
interventions for autistic children. Following this suggestion, the aim of this
study was to combine an already validated method addressing the social skills
of ASD children (i.e., the Social Story intervention) with naturally occurring
elements (e.g., companion animals) that were socially relevant to autistic
individuals.
The hypothesis of this study was that a social environment enriched hetero-
specifically by the presence of a therapy dog while reading a social story would
improve the effectiveness of Social Story method, by increasing the social abili-
ties of autistic children. In addition, the present study addressed some of the
limitations of the Social Story interventions that have been pointed out in a
recent meta-analysis (Kokina & Kern, 2010). Thus, based on the suggestions
of Kokina and Kern (2010), a comprehensive description of the participants
characteristics was included in the current study.

Materials and Methods

Participants
Three preschool children (two boys and a girl, aged 78 years) were included
in the study. The children were enrolled at the Daily Center of the Autism
Transilvania Association (Autism Transilvania Association, 2011). Written per-
mission was given by the parents of the children to disclose their personal
details. They were selected based on the following criteria: (a) previous diagno-
sis of autism, which was performed by a clinical psychologist using the Autism
Diagnostic Observation ScheduleGeneric ADOS-G (Lord et al., 2000) and
the Autism Diagnostic InterviewADI-R (Lord, Routter, & Le Couteur, 1994);
(b) lack of initiation or appropriate social response in a given social situation
during therapy or free time activities; (c) some reading prerequisites, such as
the ability to open and browse through a book and previous experience with

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stories; (e) the therapists agreement to introduce Social Story and Animal
Assisted Therapy intervention in the individualized treatment plan; and
(f) results of the pre-intervention screening regarding their ability and willing-
ness to interact with therapy dogs.
The Animal Assisted Therapy screening forms were provided by the
Romanian Association of Animal Assisted Activities and Therapy. Informed
consent forms to participate to this study were signed by the parents of each
participant. The study was approved by the Institutional Review Board of
Babes-Bolyai University, Cluj-Napoca, Romania.

Personal Characteristics of the Participants

Georgia (girl, 8 years old) was diagnosed with moderate autism, with a total
score of 35.5 on the Childhood Autism Rating Scale (Schopler, Reichler,
DeVellis, & Daly, 1980). She was included in a 3 hr/day therapy program con-
sisting of behavioral therapy, speech and music therapies. Prior the study,
Georgia showed difficulties in social communication, especially in initiating
or maintaining conversation with other children, therapists, and her parents.
Every time Georgia was kindly asked to greet anyone, she strongly protested by
exhibiting several self-stimulated behaviors, such as vocalizations, changes in
voice tonality, and crying. Prior the study, Georgia seemed visibly distressed by
any type of social interaction.
Catalin (boy, 7 years old) was diagnosed with mild to moderate autism, with
a total score of 31.5 the Childhood Autism Rating Scale (Schopler, Reichler,
DeVellis, & Daly, 1980). His intervention program consisted of two sessions
per week of Applied Behavioral Activation therapy (ABA), speech and play
therapies. His last periodical assessment indicated a mildly affected verbal and
non-verbal communication. Catalin was never observed greeting somebody,
regardless of the degree of familiarity with that person. Whenever he met a
person, Catalin exhibited self-stimulated behaviors and obviously avoided
eye contact.
Nicu (boy, 7 years old) was diagnosed with moderate autism with a total
score of 35.5 on the Childhood Autism Rating Scale (Schopler, Reichler,
DeVellis, & Daly, 1980). Nicu was included in a daily therapy program consist-
ing of behavioral therapy, speech and sensory-integration therapies. In social
situations, especially in unfamiliar settings and in the presence of unfamiliar
persons, Nicu was observed exhibiting several self-stimulated behaviors, such
as flapping his hands, loud laughing, crying, and echolalia. Before the study,
Nicu consistently refused to greet anybody. All the participants had IQ levels
between 85 and 115.

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Pre-Intervention Assessment of the Participants

Two factors are usually assessed prior the implementation of the Social Story
method: (1) recognition of basic facial expressions and (2) interest in books
(Kuoch & Mirenda, 2003). Both factors were relevant and necessary for the
intervention, because the social stories contain several perspective sentences
about the emotions expressed by other people. Recognition of the basic facial
expressions was individually assessed by placing in front the child two sym-
bols of two different emotions; that is, a happy face and a sad face (Picture
Communication Symbols; PCS, Johnson, 1994). The participant was then asked
for a receptive (point to) and an expressive (How is he/she feeling?) identifica-
tion of the emotion.
The task consisted of eight trials, with each type of identification repeated
two times per emotion, alternating the right and the left positions. All
three participants showed 100% accuracy in understanding basic facial
expressions. Interest in books was assessed by a simple checklist (Kuoch &
Mirenda, 2003), which was filled in by the therapist. The checklist consisted
of four statements related to the way the child could handle and enjoy a book
(text and images) and to the attention that he/she paid to a story read by an
adult over a period of 5 min. All the participants in the study showed interest
in books.

Setting and Materials

The study took place at a Romanian therapy center for children with ASD
(Autism Transilvania Association, 2011, www.autismtransilvania.ro). The inter-
vention took place in a carpeted therapy room (about 20 m2), where children
usually were involved in other therapeutic activities. Each participant had
one 15-min intervention session per day (i.e., Social Story or Social Story plus
Animal Assisted Therapy intervention). Georgia and Nicus sessions took place
three times per week in the afternoon, shortly after their kindergarten pro-
gram, while Catalin was assigned sessions two times per week in the morning,
before his kindergarten program. All the other unstructured social interac-
tions took place outside the therapy room (i.e., in one of the playing rooms,
where the child was left to freely play/interact with one of the volunteers from
the Center).

Social Stories
The childs therapist, together with the other three experimenters involved
in the study, designed an individualized social story for each participant. The
stories were developed using Grays (2000) construction guidelines. A specific
social skill deficit was identified for each child, as follows: Catalin and Nicus

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stories were specifically designed to teach them how to initiate and respond
to greetings (i.e., target social skill was saying hello to a new social partner; see
Appendix 1), while Georgias story was designed to teach her how to introduce
herself to a person she recently met (i.e., target social skill was saying My name
is Georgia to a new social partner).

The Therapy Dog

A Labrador dog (male, 2 years of age, named Arwan) and his handler were
involved in this study. The Animal Assisted Therapy team is certified with the
Romanian Association of Animal Assisted Therapy and Activities. Prior to the
study, the AAT team had several visits to the Autism Center. All the children
were habituated to the presence of the AAT team.

Dependent Measures and Data Collection

The following dependent variables were measured: (1) frequency of appropri-
ate social interactions relevant to the target social skill; (2) level of prompt
needed to provide the expected social response; and (3) frequency of the ini-
tiations of the social interactions relevant to the target social skill.

Frequency of appropriate social interactions relevant to the target

social skill
This measure consisted of the number of events (i.e., appropriate social inter-
actions) recorded per 15-min of each session. Because the children were given
the instructions to interact with the therapy dog only before and after the read-
ing of the social story, only the interactions with the human social partners
were quantified (i.e., in the case of Social Story plus Animal Assisted Therapy
phase). The following events were considered to be appropriate social inter-
actions: (a) any verbal, physical, or gestural appropriate response to the pres-
ence of a social partner; (b) any comment or relevant question addressed to
a social partner; (c) any appropriate response to questions or comments of a
social partner; and (d) any direct eye contact or look toward a social partner
(Scattone, Tingstrom, & Wilczynski, 2006).

Level of prompt needed to provide the expected social response

This variable was measured by using a 5-point scale rating the amount of
prompt necessary for a successful social interaction per 15-min session, as
follows:

1. A value of 5 was given if the participant did not respond to any prompt
(gestural, physical, or verbal) and engaged in self-stimulated behaviors;

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2. a value of 4 was given if the participant responded to the interaction only

after the therapists full prompt (gestural, physical, and verbal);
3. a value of 3 was given when the therapist had to use a verbal and
gestural prompt, so that the participant engaged in the social
interaction;
4. a value of 2 was given if physical prompt was needed for the participant
to respond to the social interaction;
5. a value of 1 was given if the participant responded only after the use of a
gestural prompt; and
6. a value of 0 was given if the participant independently and spontane-
ously engaged in appropriate social interaction, without any prompt.

It is important to note that the therapists prompts always followed a struc-

tured order; that is, firstgestural prompt, secondphysical prompt, third
gestural plus verbal, and forthgestural plus physical plus verbal.

Frequency of initiations of social interactions relevant to the target

social skill
This measure refers to the number of initiations of social interactions by the
participant per 15-min session. An event was recorded every time the partici-
pant initiated a social interaction (e.g., saying Hello, approaching the dog, ask-
ing a question, etc.).

Experimenters
Three graduate students were trained by the first author in data collection pro-
cedure. The training consisted of clear definitions of the dependent variables,
examples and non-examples for each category of behavior, and observations
of appropriate behavior of typically developing peers. Training continued until
the inter-observer agreement reached 80% on two successive observations.
The three observers collected baseline and intervention data on social interac-
tions during 15-min unstructured interactions per participant over a period of
10 weeks, as follows: 2 days per week for Catalin, 3 days per week for Nicu, 3 and
three days per week for Georgia.
For each participant, inter-observer agreement was measured by assessing
the level of agreement and disagreement for at least 33% of the observation
sessions during both baseline and intervention periods (Scattone, Tingstrom,
& Wilczynski, 2006). All the unstructured social interactions took place in a
playing-room, where each child was left to freely play and interact with one of
the volunteers of the Center.

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Research Design
The study included three single-case experiments. An ABAC design was used for
Nicu and Georgia, and an ACAB counterbalanced design was used for Catalin.
Each phase consisted of six sessions. In the baseline phase (A), each child was
observed for 15 min during social interactions (i.e., observation period) that
required the use of specific social skills, which were aimed to be improved by
the Social Story intervention (B) or by the Social Story plus Animal Assisted
Therapy intervention (C). Because the therapy dog could not be introduced
into the therapy room without the handler of the dog, the handler was asked
to participate in all the sessions of the experiment (i.e., the handler was placed
near the video-camera and the child was given the explanation that the han-
dler was in charge of the video-recording). For each participant, the social story
was introduced prior the observation period. After six sessions, the interven-
tion was withdrawn to the baseline condition. After permission was granted,
all the sessions were video-taped for further analysis. The video analysis was
manually done by previously trained experimenters, based on a list of behav-
ioral elements defining each appropriate social interaction involving the target
social skill. For each session, the three experimenters rated the level of prompt
needed by each child to perform the appropriate social interaction.
Inter-observer agreement was measured by assessing the level of agree-
ment and disagreement for at least 33% of the observation sessions during
both baseline and intervention. Agreements were scored when all the experi-
menters agreed that an appropriate social interaction involving the target skill
occurred or that it did not occur. Disagreements were scored when experi-
menters did not agree on the occurrence of an appropriate social interaction
during an observation session. Inter-observer agreement was calculated by
dividing the number of agreements by the total number of agreements plus
disagreements and multiplying by 100%.

Phase A (Baseline). Observers collected baseline data during six 15-min observa-
tion sessions for each participant. If the participant engaged in social interaction,
the therapist provided the level of prompt needed for a successful completion of
the social activity. No other activities were included during this phase.
Phase B (Social Story). The therapist introduced the story to the child by
saying, I have a new story for you. Let us read it! It is a story about how to greet
someone/Learning to introduce yourself. I will read the story, and then I will ask
you some questions. When they needed to, the therapists attracted participants
attention with brief comments on the accompanying pictures (e.g., Look, Nicu
is waving!). The Social Story reading was followed by a list of comprehensive

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questions (see Appendix 1) assessing the participants understanding of the

story. The questions were supposed to be answered with 100% accuracy. If
the participant did not respond correctly to the comprehensive questions,
the therapist would explain the correct answer until the child was able to offer
an accurate answer, without any prompt.
Phase C (Social Story + Animal Assisted Therapy). A well-trained therapy
dog (Labrador, male, 2 years old, named Arwan) was introduced by his handler
in the therapy room. The therapist always announced the dogs presence (Look,
Arwan is here. Lets read a story to him.), and the child was given the permis-
sion to greet and interact with the dog. The therapy dog was then given the
command to sit down in front of the participant and near the therapist. The
handler sat next to the dog and near the video-camera. The therapist would
then inform the child that the dog would be present during the story reading,
but they should not play together until the story reading is finished. After this
announcement, the therapist would read the social story, in a similar manner in
which it was read in the Social Story intervention phase. After the reading, the
child was given the permission to freely interact with the dog (i.e., greet, touch,
or hug the dog). Arwan was previously trained to bark and to lift up his paw as
a sign of greeting, and he was familiar to all the children involved in the study.

Data Analysis
Data were analyzed using SPSS version 16. Descriptive statistics was used for
the analysis of the data collected per each participant, for each dependent
measure (i.e., the frequency of the appropriate social interactions, the level
of prompt needed to perform the target social skill, and the frequency of the
social initiations). Before the implementation of each intervention, checks
were performed for the behavioral trends, by using the turning point test
(Morley & Adams, 1989). During the baseline and the intervention phases, data
were repeatedly collected (i.e., six sessions per phase) and were graphed on the
target behavior.
The Mann-Whitney U test was used to analyze the differences between
the baseline and the interventions, and between the two types of interven-
tions. The choice of the non-parametric Mann-Whitney U test was motivated
by its assumptions-free characteristics, and by the type of the design of this
exploratory investigation; that is, a single-study experiment, in which, for
each case, the data collected during the baseline and during the intervention
phases are considered independent measurements (Todman & Dugart, 2009).
The Gpower test was used for the calculation of the size effect of each type of
intervention (Cohens d); that is, the Social Story and Social Story plus Animal
Assisted Therapy intervention.

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Results

Frequency of the Appropriate Social Interactions (ASI) Relevant to

the Target Social Skill
For the first participant (Catalin), the frequency of the ASI did improve signifi-
cantly from a mean value of 0.33 (SD = 0.51) in the baseline to a mean value of
5.16 (SD = 0.75) in the first phase of the Social Story plus Animal Assisted Therapy
intervention (U= 0.00, p two-tailed < 0.05, see Figure 1). The withdrawal of the
Social Story plus Animal Assisted Therapy intervention was associated with a
decrease in the frequency of ASI to a mean value of 3.33 (SD = 0.51), followed
by an increase of the frequency when the Social Story intervention was intro-
duced in the phase C (see Figure 1), but with no statistical significance. The size
effect when comparing the two interventions was Cohens d = 0.83 (p < 0.05).
For Nicu and Georgia, no significant increase of the frequency of ASI was
found, neither after the introduction of the Social Story intervention, nor after
the introduction of the Social Story plus Animal Assisted Therapy intervention
(see Figure 1). The graphical analysis indicates that, after the introduction of
the Social Story intervention, the frequency of ASI decreased as follows (Figure
1): (1) for Nicufrom a mean level of 4.16 (SD = 0.98) in the baseline (phase A;
Figure 1) to a mean value of 4.83 (SD = 1.16; phase B); (2) for Georgiafrom a
mean value of 2.00 (SD = 0.63) in the baseline (phase A) to a mean value of 3.16
(SD = 0.40; phase B). No treatment reversal occurred when the intervention
was withdrawn during the subsequent A phases for Nicu and Georgia.

Level of Prompt Needed to Provide the Expected Social Response

For Catalin, as soon as the Social Story plus Animal Assisted Therapy interven-
tion was introduced, there was a statistically significant decrease in the level of
prompt (see Figure 2), from a mean value of 5.00 (SD = 0.00) to a mean value
of 0.66 (SD = 0.81) after the first intervention (phase C; U = 0.00, p < 0.02, see
Figure 2). When the Social Story plus Animal Assisted Therapy intervention was
withdrawn, the level of prompt did increase (mean value = 2.50, SD = 0.51), yet it
remained lower compared to the baseline values (see Figure 2). A moderate effect
(Cohens d = 0.47; p < 0.05) was shown when comparing the two interventions.
For the second participant (Nicu), the data showed a high variability and
a decreasing trend during the initial baseline (see Figure 2). When the Social
Story intervention was introduced (phase B), the decrease in the level of
prompt was observed (mean value = 1.50, SD = 0.83). At the subsequent with-
drawal of the Social Story intervention, the mean value of the level of prompt
did not change, indicating no treatment reversal (see Figure 2). When Social
Story plus Animal Assisted Therapy was introduced, the mean value of the

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Appropriate Social Interaction

7
Baseline SS+AAT Baseline SS
6
Ctlin
5
4 Appropriate
social
3 interaction
2
1
0

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Baseline SS Baseline SS+AAT

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Appropriate
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interaction
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Baseline SS Baseline SS+AAT
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interaction
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Figure 1 Frequency of the appropriate social interactions (mean values) for Catalin, Nicu, and
Georgia during the four phases of the experiment. Each intervention phase included
six sessions, where SS means Social Story intervention, and SS + AAT means Social
Story plus Animal Assisted Therapy intervention. The target social skill for Catalin and
Nicu was the ability to greet a new social partner, whereas the target social skill for
Georgia was the ability to introduce herself to a new social partner.

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Level of Prompt
6 Baseline SS+AAT Baseline SS

5
Ctlin
4

3 Level of
prompt
2

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prompt1

prompt2

prompt3

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3 Nicu

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2 prompt

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6 Baseline SS Baseline SS+AAT

4 Georgia
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Figure 2 Level of prompt needed to provide the expected social response (mean values) for
Catalin, Nicu, and Georgia during the four phases of the experiment. The level of
prompt was measured using a 5-point scale, where a value of 5 was given if the
participant did not respond to any prompt (gestural, physical, or verbal) during the
15-min session and a value of 0 was given if the participant independently and
spontaneously engaged in appropriate social interactions without any type of prompt.

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level of prompt decreased to 0.66 (SD = 0.51), but with no statistical signifi-
cance (phase C, Figure 2).
For the third participant (Georgia), the initial baseline data indicated that
she needed full prompts most of the time to appropriately interact with a
social partner (see Figure 2). The introduction of the Social Story was associ-
ated with a decrease of the level of prompt from a mean value of 4.50 (SD =
0.54) to a mean value of 1.33 (SD = 0.81). The withdrawal of the Social Story
intervention indicated no treatment reversal (Figure 2). Compared to baseline,
the level of prompt had a statistically significant decrease during the introduc-
tion of the Social Story plus Animal Assisted Therapy intervention (U = 4.5,
p < 0.05; Figure 2).

Frequency of the Initiations of Social Interactions (ISI)

For all the three participants, no initiation of social interactions during the initial
baseline was observed. The introduction of the Social Story plus Animal Assisted
Therapy intervention had a statistically significant effect by increasing the fre-
quency of ISI for all the participants. Thus, in the case of Catalin, the Social Story
plus Animal Assisted Therapy intervention was associated with a significant
increase of the frequency of ISI (mean = 2.33, SD = 0.11; U = 0.00, p < 0.05). The
withdrawal of this intervention was followed by treatment reversal (Figure 3).
After the introduction of the Social Story intervention, a small increase in the fre-
quency of the social initiations was observed (mean = 0.50, SD = 0.54; see Figure
3), but it was not statistically significant from the baseline level.
For Nicu, there was no significant difference in the level of ISI between the
baseline and the Social Story intervention (Phase B; see Figure 3). At the intro-
duction of the Social Story plus Animal Assisted Therapy intervention, there
was an increase in both the variability of the data and in the mean rate of social
initiations; that is, the mean value for Phase A = 0.16 (SD = 0.4), the mean value
for Phase B = 0.16 (SD = 0.4), and the mean value for Phase C = 2.00 (SD = 0.89).
For Georgia, the introduction of the Social Story intervention was associated
with a slight increase of the frequency of ISI (see Figure 3). After the withdrawal
of this intervention (i.e., the second A phase), the frequency of ISI continued
to slowly increase (Figure 3). The introduction of the Social Story plus Animal
Assisted Therapy intervention was associated with a sudden and statistically
significant increase in the frequency of ISI, which continued to improve after
each intervention session (Figure 3). The frequency of ISI was significantly
higher in the Social Story plus Animal Assisted Therapy i ntervention compared
to the second baseline phase (U = 1.5, p < 0.05; see Figure 3). The comparison of
the Social Story and Social Story plus Animal Assisted Therapy interventions

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Interaction with a Therapy Dog|doi 10.1163/15685306-12341326 15

Initiation of the Social Interaction

Baseline SS+AAT Baseline SS
4

3
Ctlin

2 Initiation

0 17
7
8
9
10
11
12
13
14
15
16
18
19
20
21
22
23
24
1
2
3
5
4
6

Baseline SS Baseline SS+AAT

3
Nicu
2
Initiation
1

0
17
7
8
9
10
11
12
13
14
15
16
18
19
20
21
22
23
24
1
2
3
5
4
6

Baseline SS Baseline SS+AAT

3
Georgia
2
Initiation
1

0
17
7
8
9
10
11
12
13
14
15
16
18
19
20
21
22
23
24
1
2
3
5
4
6

Figure 3 Frequency of the initiations of social interactions (mean values) for Catalin, Nicu,
and Georgia during the four phases of the experiment. Each intervention period
included six sessions, where SS means Social Story intervention and SS + AAT means
Social Story plus Animal Assisted Therapy intervention.

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16 doi 10.1163/15685306-12341326|grigore and rusu

indicates a high effect size for all three participants; that is, Cohens d = 0.83 for
Catalin, d = 0.92 for Nicu, and d = 0.79 for Georgia, p < 0.05.

Discussion

Several studies on the therapy methods aiming at decreasing the social deficits
of autistic children have recently emphasized the necessity of performing this
type of investigation in close-to-real-life situations with naturally occurring
stimuli (Prothmann, Ettrich, & Prothmann, 2010; Klin, Jones, Schultz, Volkmar,
& Cohen, 2002; Klin, Schultz, & Volkmar, 2003). Companion animals, such as
dogs, not only provide this type of multi-sensorial, natural stimulation, but
also some data suggest that autistic children can interact better with animals
than humans (Leslie, 1994; Prothmann, Ettrich, & Prothmann, 2010).
In this light, an exploratory investigation was performed, which combined
two methods that have proved to increase the level of social abilities of autistic
children: Social Story intervention (Gray, 2000) and Animal Assisted Therapy.
The main hypothesis was that a naturally enriched social environment (the
presence of a therapy dog) would improve the effectiveness of Social Story
method in enhancing the social abilities of three preschool autistic children.
Two social skills were targeted (i.e., the ability to greet a social partner and the
ability to introduce oneself to a social partner), while a standard single-subject
research design was followed. The results are discussed below, for each depen-
dent measure.
The data show that Social Story plus Animal Assisted Therapy is associated
with a statistically significant increase in the frequency of the appropriate
social interactions for one of the three participants to the study: Catalin. As
Figure 3 shows, this hybrid intervention is associated with an increase of the
appropriate intervention for the other two participants, but without statistical
significance. Even though all the participants enjoyed the presence of the dog,
Catalin consistently showed the highest level of enthusiasm every time Arwan
(the therapy dog) visited the Autistic Center. His enthusiasm toward the dog,
which was translated into prosocial behaviors, such as hugs and touching the
dog, might have contributed to the significant effect of the Social Story plus
Animal Assisted Therapy intervention.
Additionally, these effects might be explained by the fact that Catalin had
a mild to moderate score on the autism scale, compared to the other two
participants who had moderate scores. In the case of Georgia, the graphical
analysis indicates that, even though with no statistical significance, compared
to baseline, both methods (Social Story and Social Story plus Animal Assisted

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Interaction with a Therapy Dog|doi 10.1163/15685306-12341326 17

Therapy) are associated with an increase in the frequency of the appropriate

social interactions. For Nicu, the graphical analysis indicates that the fre-
quency of the appropriate social interactions remained relatively constant
throughout the experimental phases. One can explain this result by the fact
that Nicu might have automatically learned the appropriate social interactions
relevant to the target skills, in spite of his inability to have specific reactions to
different social partners.
Compared to the baseline condition, the Social Story plus Animal Assisted
Therapy intervention had a statistically significant decreasing effect on the
level of prompt for Catalin and Georgia, while no statistically significant effect
was observed for the Social Story intervention alone. However, the graphi-
cal analysis indicates that the Social Story intervention was associated with
a decrease of level of prompt for all the participants, in line with the results
reported so far in the literature.
We assume that the lack of statistical significance of the effects of Social
Story intervention on the decrease of level of prompt is due to the small sam-
ple size of this exploratory investigation. However, even though this study is
based on a small sample size, the results indicate that the presence of the dog
might increase the efficiency of Social Story intervention (i.e., by decreasing
the level of prompt offered by the therapist).
All the participants showed statistically significant increases in the fre-
quency of the social initiations in the presence of the therapy dog. Compared
to the baseline and the Social Story intervention phases, the frequency of social
initiations was significantly higher for all three autistic children at the introduc-
tion of the Social Story plus Animal Assisted Therapy intervention. Our results
indicate that the dog might have acted as a facilitating agent of the social inter-
actions for the autistic children, in the context of Social Story reading.
In summary, our results suggest that the presence of a dog while reading a
social story can bring important social improvements by increasing the fre-
quency of social initiations and by decreasing the level of social prompt that
the autistic children usually need to perform appropriate social interactions.
Our findings are in line with the results of previous studies on the effectiveness
of Animal Assisted Therapy in enhancing the social motivation and communi-
cation of autistic children (Barol, 2006; Carenzi, Galimberti, Buttram, & Prato
Previde, 2008; Solomon, 2010).
One potential limit of the study is that the intervention program did not
include the phase Animal Condition (i.e., dog presence alone). However, the
aim of this study was to explore whether adding the dogs presence into a
standardized therapeutic procedure (i.e., Social Story method) might improve
the efficiency of the target procedure. We are fully aware that in order to clarify

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18 doi 10.1163/15685306-12341326|grigore and rusu

the mechanism of change for the effects of dog presence on the social abilities
of autistic children, further studies should include the phase Animal Condition.

Conclusion

The method of Social Story (Gray, 2000) is widely used by specialists working
with autistic children in Romania in clinical settings and in centers founded by
parents of autistic children, such as the Autistic Center that hosted our inves-
tigation. Also, recent surveys indicate that dogs are the most common pets in
this country (Cocia & Rusu, 2010), and they are affordable companion animals to
Romanian families. The interest in Animal Assisted Therapy has increased over
the last five years at national level, as proven by the educational and scientific
activity of the Romanian Association of Animal Assisted Activity and Therapy.
In this light, the inclusion of a well-trained dog or an AAT team (the handler
and the therapy dog) in the therapy environment of autistic children would
be a low-cost and efficient way of improving the results of the Social Story
methods used to improve the social skills of ASD individuals. This comes in
line with the suggestion of Prothmann, Ettrich, and Prothmann (2010) to use
an enhanced methodological spectrum for the experimental studies of chil-
dren with autism. Although the mechanisms underlying these positive effects
of animals on the social communication abilities of the autistic children are
not yet clear, the clinical implications of bringing therapy dogs to interact with
children with ASD to improve specific deficits deserve future investigation.

Acknowledgements

The participation of Alina Simona Rusu in this research was supported by CNCS-
UEFISCDI, project number PN-II-RU-TE-20113-0080. The authors would like to
thank the Autism Transilvania Association (Cluj-Napoca, Romania) for facilitat-
ing the participation of the three autistic children in this investigation.

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Appendix 1. An example of a Social Story designed for Nicu (i.e., target social skill How
to say hello), based on the Grays (2000) guidelines.

People greet each other when they meet people they already know.
Whenever I meet a person I already know, that person might smile to me and say:
Hello, Nicu.
I should smile, too, and reply to him/her: Hello. He/she might stop and talk to me.

People feel happy when I say Hello to them.

When I meet Bianca, I should look toward her and say to her: Hello, Bianca. When
Bianca leaves the room, I can say to her: Bye-bye, Bianca and wave to her. Bianca
should feel happy when I greet her.

When my mum will show up at the Center, I should go to her and say to her: Hello,
mum. Then I should give her a hug. My mum should feel happy when I greet her by
saying hello and hugging her.

It is nice to greet a person I know. People like when I smile to them and when I greet
them.

Comprehensive Questions:

1.What are you supposed to do when you meet a person you already know?
2.How do people feel when you say hello to them?
3.What are you supposed to say to your mum when she shows up at the Center to
pick you up?

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