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

Abstract

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

The World Health Organization (2007) defines participation as one’s involvement in daily situations. Occupational therapy (OT) practitioners are positioned to enhance performance and participation, including social participation, across various environments in which children engage (Khetani & Coster, 2018). Social participation is defined by the Occupational Therapy Practice Framework as “activities that involve social interaction with others, including family, friends, peers, and community members, and that support social interdependence” (American Occupational Therapy Association [AOTA], 2020, p. 34). Specific performance patterns related to social participation addressed by occupational therapists (OTs) include, but are not limited to, initiating and terminating social interaction, physically supporting social interaction (i.e., looks, turns, touches, regulates, places self), shaping the content of social interaction (i.e., questions, replies, expresses emotions, discloses, disagrees, thanks), and maintaining the flow of interactions (i.e., transitions, times responses, takes turns) (AOTA, 2020). It is imperative to expand knowledge on interventions that can help OTs maximize clients’ social participation when engaging in meaningful occupations (Khetani & Coster, 2018).

OTs have used several approaches to facilitate social skills and participation among individuals with autism spectrum disorders (ASD) (Tanner et al., 2015). They have included and drawn on several different theories, including behavioral, social learning, cognitive theories, and sensory processing theories (Helfrich, 2018; Tanner et al., 2015). One intervention approach, social narratives (inclusive of Social Stories), has been widely used in various settings to help children understand social situations, increase coping skills, develop self-care skills, and improve academic abilities. Social Stories were introduced by Carol Gray, who worked with children with ASD and saw a need to help children learn social skills (Gray, 2018a). The stories are written to share easily understood social information by describing concepts, skills, or situations and their common responses in a specific style and format (Gray, 2010). Social narratives draw on several theoretical frameworks. According to Gray and Garand (1993), Social Stories address one of the cognitive impairments in ASD, that of difficulty reading emotions, intentions, and thoughts (theory of mind) which affects children’s ability to understand and read social cues of others. Behavior theory also has been associated with social narratives in that the “scenario” or situation provides the stimulus, and the response is the desired behavior shown in the story. Social narratives also draw on social learning theory (Bandura, 1977) and the importance of observational learning. In social narratives, the desired behavior is modeled for the child. These theoretical frames of reference are widely used in occupational therapy practice.

In 1993, Gray and Garand (1993) formalized Social Stories by providing a rationale, guidelines, and techniques for implementation. These guidelines serve as a fidelity check to determine whether Social Stories adhere to Gray’s definition. Social Stories should be written in the first person; use positive, reassuring language to answer who, what, when, where or why questions; include descriptive and directive sentences at a ratio of 2:1; and include pictures, when possible (Gray, 2018b). Attempts have been made to ensure fidelity by trademarking the term Social Story and limiting training to Social Stories Satellite Schools and Services, which receive ongoing consultation from Gray or her designee (Gray, 2018c). However, other variations, referred to as social narratives, have used many features of Gray’s Social Story to meet similar goals.

Numerous reviews examined the quality and efficacy of Social Stories and social narratives (Ali & Frederickson, 2006; Bozkurt & Vuran, 2014; Karkhaneh et al., 2010; Leaf et al., 2015; McGill et al., 2015; Qi et al., 2018; Reynhout & Carter, 2007; Sansosti et al., 2004; Test et al., 2011). The results of the reviews were mixed, with disparate outcome measures. Therefore, there remains a call for more research into their effectiveness (Reynhout & Carter, 2006). The most recent systematic review by Qi et al. (2018) only included single-case research design studies published prior to July 2013. Thus, although it is a current reference, it does not include articles published in the last seven years. This scoping review aims to identify and synthesize studies utilizing social narratives (inclusive of Social Stories) targeting behavior change in individuals with ASD to identify gaps in the literature. Scoping and systematic reviews are both tools, involving a structured process, that are employed to accomplish different goals. Systematic reviews are often used to determine the quality of evidence on a particular topic, while a scoping review is performed to determine the scope of the literature (Munn et al., 2018). A scoping review instead of a systematic review was chosen because the purpose was to identify the scope or coverage of a body of literature and identify knowledge gaps by providing an overview or map of the evidence (Munn et al., 2018). Although most social narratives target social skills, we wanted to determine other outcomes examined in the research.

Methods

This scoping review utilized the framework established by Arksey and O’Malley (2005) and updated by Levac et al. (2010), the Joanna Briggs Institute (Peters et al., 2015), and Tricco et al. (2016).

Identifying the Research Question.

The guiding questions for this review were: What is the scope of social narrative interventions used for individuals with ASD? What behavior change outcome measures are evaluated? What research designs are used?

Identifying Relevant Studies.

To examine the use of social narratives for individuals with ASD, a search of five databases (PsycINFO, Cochrane Systematic Database, PubMed, CINAHL, and ERIC) was conducted. These databases were selected based on information obtained from a preliminary search which indicated that educators and therapists primarily implemented social narrative interventions. Articles published with a population term- [(Autis* OR ASD OR Asperger* OR PDD-NOS)] AND an intervention term [(“Social Story/ies” OR “Social Narrative/s”)] were considered. In addition, the authors reviewed reference lists of identified articles in systematic reviews and literature reviews published from 2007 (Bozkurt & Vuran, 2014; Karkhaneh et al., 2010; Leaf et al., 2015; McGill et al., 2015; Qi et al., 2018; Reynhout & Carter, 2007; Test et al., 2011) to ensure identification of all relevant articles.

Study Selection.

Articles were included if: 1) the sample included individuals with Autism, Asperger, Pervasive Developmental Disorder-Not Otherwise Specified, or Autism Spectrum Disorders; 2) the publication date was between January 2007 and February 2018; 3) a social story or social narrative was used as an intervention; 4) the article was published in English. Articles were excluded if they were: 1) literature reviews; 2) case studies without intervention; 3) a qualitative understanding of the experience of the user (i.e., teacher’s perspectives of implementing social narrative); 4) without a control or alternate condition; or 5) comparisons of two different modes of social narrative delivery (i.e., iPad vs. paper) without reporting on a targeted behavior, as we wanted to review studies that test the efficacy of the social narrative, not the method of delivery. Participant age was not an inclusion/exclusion criteria as we wanted to determine with whom social narratives were used. In addition, dissertations that met the criteria were considered because, in some instances, they may be more easily obtained by the public (as they are not often behind a paywall) and represent the existing literature.

The search yielded 445 articles, and the review of references produced five additional articles. Following the removal of duplicates, 314 articles remained. Article titles and abstracts were reviewed for relevance by two independent reviewers using Covidence systematic review software, and a third reviewer resolved any conflicting decisions. Fifty-six articles were included in this review. See the PRISMA flowchart (Figure 1).

Figure 1.

PRISMA flowchart

Charting the Data.

Relevant information from each article was identified through data charting. General information about the article was documented (i.e., author(s), publication date, study design, number of participants) with particular attention paid to targeted behavior and results to different people or settings.

Collating, Summarizing, and Reporting the Results.

After reviewing all the articles for themes related to the guiding questions of how social narratives are used to encourage behavior change, the authors chose to collate the articles based on two macro-categories (1) Reducing Disruptive Behaviors and (2) Increasing Desired Behaviors in order to reduce the many outcomes into fewer dimensions which reflect the primary uses of social narratives. Outcomes were then classified into subcategories based on the researchers’ descriptions of the target behaviors. These subcategories contribute to understanding how social narrative interventions encourage behavior change for individuals with ASD. The authors acknowledge that in some instances, the reduction of one behavior can also be interpreted as its inverse behavior (e.g., reducing out-of-seat time could also be categorized as increasing time in-seat). Therefore, the authors of this review have chosen to group them based on the researcher’s initial description.

Results

A total of 56 articles were included in this review. Table 1 summarizes the articles, including: author(s), publication date, study design, number of participants, intervention implementation location (i.e., home or school), targeted behavior, results, and maintenance of the behavior or generalization to different people or settings. Adherence to Social Story fidelity was noted based on the authors’ self-identification or sample social narrative when provided.

Table 1.

Summary of Social Story (SS) Articles Included in this Review

Author	Study Design	Participants // Intervention Location	Targeted Behavior	Results	Maint	Gen
Aboulafia (2012) * ^ < >	Multiple Single Subject, ABAB reversal	N=7 (age 5 y.o.) // School	Sharing toys, positive social interaction and eye contact, asking someone to play, appropriate classroom behavior	Effective for reducing undesirable behaviors; less effective for increasing desired behaviors; Significant effect sizes (Cohen’s d) for baseline vs intervention, withdrawal vs reinstatement, treatment vs follow-up for various participants and behaviors.	+	+
Abraham (2009) * ^ < >	Multiple Baseline	N=4 (age 7–14 y.o.) // School	Social talking, inappropriate vocalizations, appropriate responding	Trends observed for each participant. Behavior improved for most, increases in social talking and appropriate responding noted, while inappropriate vocalizations decreased.	+	+
Acar, et al. (2017) >	Adapted Alternating Treatment	N=3 (age 6, 7, 10 y.o.) // Home	Offer assistance, identify himself, ask permission to access objects	Participants learned and generalized the skills acquired via SS and VM with 100% accuracy	+	+
Al zyoudi, et al. (2016) ^ < >	AB	N=3 (age 7, 8 y.o.) // School	Preparing to leave in an appropriate way, behaving appropriately during circle time	Social interaction behaviors increased for all participants.	+	−
Anderson, et al. (2016) <	Multiple Baseline	N=3 (age 5, 6 y.o) // School	Aggressive behavior	Decreased physical aggression	−	−
Anthony (2015) * ^ >	Alternating Treatment ABAC	N=3 (age 11–14 y.o.) // Community	Verbal initiations and on topic responses	Utilizing Non-overlap of All Pairs (NAP), 2 of 3 participants increased percentage of on topic responses and verbal initiations.	+	+
Ashmeade (2017) * ^ >	Multiple Baseline	N=3 (age 13, 14, 15 y.o.) // Home	Securing attention, initiating comments, initiating requests, and contingent response to a peer’s initiations	Medium to large effect size (d-index) indicated increase in mean duration and frequency of social engagement for 2 of 3 participants.	+	+
Beh-Pajooh, et al. (2011) <	Multiple Baseline	N=3 (age 8, 9 y.o) // School	Crying, wandering the classroom, laying down on desk	Two of 3 participants demonstrated significant reduction in target behaviors. Effect sizes for crying (PND=0.71) and wandering the classroom (PND=0.79) were moderate. Frequency for laying down on the desk was inconsistent, PND was zero.	−	−
Bernad-Ripoll (2007) >	Single Subject, AB	N=1 (age 9 y.o) // Home	Recognizing emotion; appropriate responses for each emotion	Increased ability to recognize and label emotions in self and in others.	−	+
Bricker (2016) *^>	Multiple Baseline	N=4 (age 5, 6 y.o.) // School	Increase greeting and prosocial behaviors	Increase in prosocial behaviors and greetings in 3 of 4 participants; intervention more successful when presented by therapist knowledgeable about story content.	−	−
Chan & O-Reilly (2008) * < >	Multiple Baseline	N=2 (age 5, 6 y.o.) // School	Inappropriate vocalizations, social initiations	Inappropriate vocalizations decreased and social initiations increased for both children	+	−
Chan (2010) * ^ < >	Multiple Baseline	N=6 (age 7–9 y.o.) // School	Appropriate sitting, appropriate eye contact, attending to the teacher during group, decreasing inappropriate comments, end of the day routine	Improvements in individualized target behaviors for 5 of 6 participants.	−	−
Chan, et al. (2011) < >	Multiple Baseline	N=3 (age 8 y.o.) // School	Appropriate sitting, attending to the teacher during group, working independently	Mild to moderate improvement in target behaviors	−	−
Cihak, et al. (2012) <	Multiple Single Subject	N=4 (age 11–14 y.o.) // School	Off task behaviors/attention seeking behaviors	Task engagement improved only after viewing the video SS that matched their specific function of behavior.	−	−
Cowan (2016) ^ * >	Multiple Single Subject, Reversal	N=4 [N=2 receiving SSI] (age 8–12 y.o.) // Community	Eye-Contact (Looking at peer, researcher, or leader); Imitation; Smiling	PND for smiling was very low for 1 participant and moderate for the other. Imitation behavior scores were inconsistent and eye contact did not appear to be influenced by SS.	−	−
Crozier & Tincani (2007) <	Multiple Single Subject, ABAB and ABACBC	N=3 (age 4–6 y.o.) // School	Replace undesirable behaviors with alternatives such as sitting at circle time, talking with peers, appropriate play with peers	Inappropriate behaviors were replaced with desirable behaviors for all participants	+	−
Darley (2014) * ^ >	Multiple Baseline	N=5 (age 3–4 y.o) // School	Teach early executive function behaviors: joint attention,	Using Cohen’s d, effect sizes were d>.5 indicating significant change for 4 of 5 participants. Two participants generalized to the new setting.	+	+
Dodd, et al. (2008) < >	Multiple Baseline - across behaviors and participants	N=2 (age 9 and age 12 y.o.) // Home	Excessive direction giving and compliments; being a good sport	Frequency of giving directions decreased by 43.8% and compliment giving increased by overall 19.5% for both participants	+	−
Doody (2012) * ^ >	Multiple Baseline	N=3 (age 7–9 yo.) // School	Socially appropriate interactions, non-verbal or verbal	Each participant demonstrated gains. Mean percentage of intervals of socially appropriate interactions increased from 1.2% in baseline to 57.9% in intervention	+	−
Doss (2013) <	Single Subject, AB	N=1 (age 7 yo.) // Home	Disruptive behavior during homework parental stress and family quality of life (QoL)	SSI did not result in expected decrease in behaviors, parental stress or increase in QoL.	−	−
Gikas (2013) ^ < >	Multiple Baseline	N=3 (age 5–9 yo.) // School	Initiating interaction, use technology to communicate appropriate responses, gain peer attention and to initiate requests for peers to play	All participants made gains in initiation skills; little maintenance and no generalization of skills.	+	+
Graetz, et al. (2009) * <	Multiple Baseline	N=3 (age 12–15 y.o.) // School	Individualized behaviors: refusal to stand, use of a high-pitched voice, and placing hands/objects in mouth.	Individualized target behaviors improved for 2 of 3 participants and these improvements were maintained.	+	+
Halle, et al. (2016) >	Multiple Baseline	N=4 (age 12–14 y.o.) // School	Social responses when greeted	Consistent improvements in social responses.	−	+
Hanley-Hochdorfer, et al. (2010) >	Multiple Baseline	N=4 (age 6–12 y.o.) // School	Verbal initiations and contingent responses to peers.	Little or no effect across baseline, intervention, and follow-up using PND scores.	+	−
Hillman (2011) * ^ >	Multiple Baseline	N=4 (age 5–18 y.o.) // Home	Appropriate social behaviors	Data reported for frequency of behaviors. Improvement for all, some more than others.	+	−
Hung & Smith (2011) * <	Multiple Single (ABAB)	N=1 (age 6 y.o) // School	Shouting aloud	Data reported as proportion of intervals per session and used visual analysis. Participant exhibited decrease in target behaviors	−	−
Hutchins & Prelock (2013) >	Multiple Baseline	N=20 (age 4–12 y.o.) // Home	Behavior, communication	SS for behavior change were effective 64.7% of the time; communication stories were effective 52.6% of the time based on parental ratings. Tau-U was used to validate visual analysis and to measure effect size.	+	−
Jeekratok, et al. (2014) >	Experimental, Pre/Post Test	N=10 (age 7–10 y.o.) // School	Arranging and organizing belongings, empathizing with others, following rules	Improvements in all targeted behaviors from pre-to post test. Wilcoxon signed rank test and t-tests used to analyze data. t-values and z-scores were significant.	−	−
Kagohara, et al. (2012) >	Multiple Baseline	N=2 (age 10 y.o.) // School	Greet school staff	Both students learned to greet familiar adults at school, with different degrees of success.	−	−
Karayazi, et al. (2014) >	Multiple Baseline	N=1 (age 22 y.o.) // Community	Greeting behavior, nose-wiping	Participant increased greeting behaviors and nose-wiping.	−	−
Kassardjian et al. (2014) * >	Multiple Single Subject	N=4 (age 5 y.o.) // School	Responding to peers	One social skill taught via teaching interaction, one via SS and one with no intervention. Teaching interaction procedure is efficacious; SS not effective.	+	−
Klett & Turan (2012) >	Multiple Baseline	N=3 (age 9–12 y.o.) // Home	Independent completion of a typical bathroom routine for changing a sanitary pad	All participants increased skill in changing a sanitary pad using a menstruation checklist.	−	+
Kokina (2012) * ^ < >	Multiple Single Subject, ABAB reversal	N=3 (age 9–11 y.o.) // School	Disruptive behavior, on task behavior, school transitions	Mixed effectiveness. SSI deemed ineffective using PND.	+	−
Krasch (2014) * ^ < >	Multiple Baseline	N=4 (age 4–5 y.o.) // School	Verbal social initiations and maladaptive behaviors	Visual analysis used to identify level, trend and variability. PND calculated. Inconsistent findings; Intervention for was effective 1 for 1 of 4 participants.	+	+
Leaf (2011) ^ >	Multiple Baseline	N=6 (age 5–13 y.o.) // School	Social communication skills: securing attention, initiating comments, initiating requests, contingent responses	Partially effective in increasing some targeted specific social communication skills of each child. Some generalization in 3 boys. Maintenance weak	+	+
Litras, et al. (2010) * >	Multiple Baseline	N=1 (age 3 y.o.) // Home	Social Skills: greeting, inviting to play, responding to social invitations by others	All three target behaviors improved and increased even during follow up. Behaviors generalized to other settings in home and school.	+	+
Mancil, et al. (2009) * <	Multiple Single Subject, ABABCBC	N=3 (age 6 – 9 y.o.) // School	Pushing	Decrease in frequency of problem behavior for each participant.	+	+
Nasr (2015) * ^ < >	Multiple Baseline	N=4 (age 11 y.o.) // School	Increasing social behavior, seeking attention, initiating, contingent responses	Effect size calculations included PND and percentage of data points exceeding the median (PEM). Visual inspection changes in level, trend, and variability. Inconsistent results, some improvement in target behaviors but not for all participants.	−	−
O’Handley, et al. (2015) >	Multiple Baseline	N=6 (age 16–19 y.o.) // School	Eye contact	Moderate improvements in eye contact. Effect size was calculated utilizing Nap and Tau-U.	−	+
Okada, et al. (2008) ^ <	Multiple Single Subject, ABCA and AABACA Reversal	N=2 (age 12, 13 y.o.) // School	Persistent and aggressive verbal behaviors, sitting appropriately on a sofa	Inconsistent results, some improvement in target behaviors but not for all participants	−	−
Olçay-Gül & Tekin-Iftar (2016) >	Multiple probe	N=3 (age 12–16 y.o.) // Various	Greeting skill, asking permission, expressing happiness	Targeted social skills improved and were maintained over time and generalized to different people and settings.	+	+
Ozdemir (2008) < >	Multiple Baseline	N=3 (age 7–9 y.o.) // School	Using a quiet voice in class, sitting appropriately, waiting in line to get lunch in cafeteria	Significant reduction in targeted disruptive behaviors for all participants.	+	−
Ozdemir, et al. (2008) (2)*>	Multiple Baseline	N=3 (age 5, 6 y.o.) // School	Duration of appropriate social engagement	Increase in duration of appropriate social engagement for all participants; two participants showed generalization to a classroom.	+	−
Pane, et al. (2015) <	Alternating Treatment	N=2 (age 10, 15 y.o.) // Home	Facial grimacing, noncontextual smiling laughter	SS that matched the function of the behavior decreased target behaviors for both participants.	+	−
Perry (2011) * ^ <	Interaction element design (ABCBC, ABCBCB)	N=4 (age 6–10 y.o) // School	Inappropriate and appropriate behaviors	SS effective at decreasing inappropriate behaviors and increasing appropriate behaviors for 3 participants.	−	−
Quilty (2007) <	Multiple Baseline	N=3 (age 6–10 y.o.) // School	Physical aggression, inappropriate class behaviors and saying “go home”	Decrease in target behaviors	+	−
Quirmbach, et al. (2009) >	RCT - SS compared to directive social narrative compared to control story	N=45 (age 7–14 y.o.) // Community	Greeting behaviors, requesting to play a game, asking another person what game they wanted to play, accepting another’s choice of game	SS and directive social narrative formats were equally effective in eliciting, generalizing, and maintaining the targeted social skills in participants who had prior game play experience. Repeated measure ANOVA and mixed ANCOVA showed significant improvement across trials.	+	+
Reichow & Sabornie (2009) >	Withdrawal Design with a cue fading phase	N=1 (age 11 y.o.) // School	Acceptable greeting initiations	Increased verbal greeting initiations during intervention and remained greater than baseline during cue fading.	−	−
Samuels & Stansfield (2011) <>	Multiple Baseline	N=4 (age 17–32 y.o.) // Community	Socially inappropriate behaviors and pro social skills	Variable results. Outcomes more positive for reducing socially problematic behaviors vs increasing prosocial behavior. All target behaviors trended towards baseline by probe phase.	+	−
Sansosti & Powell-Smith (2008) >	Multiple Baseline	N=3 (age 6–10 y.o.) // School	Social Communication: Joining in/Initiating conversation and activities; maintaining conversations	All participants increased in social communication. Two of 3 showed increased social communication during maintenance	+	+
Scattone, et al. (2008) >	Multiple Baseline across behaviors	N=1 (age 9 y.o) // Medical Center	Eye contact, smiling, and social initiations	Using PND, eye contact and reciprocal interactions are 100% (highly effective); smiling is 32% (unreliable). Medium effect size for smiling and large effect for eye contact and initiations.	−	+
Schneider & Goldstein (2010) >	Multiple Baseline	N=3 (age 5–10 y.o.) // School	On-task behavior when preparing to leave, verbalizing only when asked by teacher, raising hand and waiting before speaking, sitting and following directions during circle time	Targeted on-task behaviors improved for all participants. Large effect size (d=1.33).	+	−
Thompson & Johnston (2013) >	Multiple Baseline	N=3 (age 3–5 yo.) // School	Stay seated during snack times/circle activities; engage in tactile play with teachers and peers	All 3 children had increased frequency of desired behavior which was sustained during maintenance period.	+	+
Vandermeer, et al. (2015) * >	Multiple Baseline	N=3 (age 4 yo.) // School	On task behavior “while seated, attention to task, materials, or teacher”	Combination of the SS together with iPad was effective for only 1 of 3 participants.	−	−
Watts (2008) * ^ <	Multiple Baseline	N=6 (age 6–9 yo.) // School	Disruptive behaviors	One participant showed decrease in disruptive behaviors; 4 showed no significant decrease; 1 was inconclusive.	−	−
Wright & McCathren (2012) >	Multiple Baseline	N=4 (age 3–7 yo.) // School	Positive interaction and response to peer initiation	Moderate effectiveness in increasing prosocial behavior in 3 of 4 participants; problem behaviors of all participants moderately decreased; maintenance demonstrated over 1 month.	+	−

Note.

^*Authors report utilizing Gray’s fidelity criteria

^{^}Dissertation/Thesis

^<Disruptive Behaviors Targeted

^>Desired Behaviors Targeted

SS=Social story(ies); RCT= Randomized controlled trial; Maint=Maintenance was examined; Gen=Generalization was examined

Results of the review process indicated that just over 70% of the interventions were implemented in the school setting. The remaining 30% took place in the home and community settings. Most participants were school-age (5 –12 years old). However, approximately 20% of the studies included participants 12 years of age through adulthood, and nearly one-fifth of the participants were under five years old. While all of the articles referenced Gray’s guidelines in some way, 41% of the authors indicated that they were taking steps to adhere to Gray’s fidelity measures. Nearly all of the studies included in this review utilized single-subject designs with only one randomized controlled trial. Nineteen of the studies included were dissertations. Please see Table 1.

Descriptive Summary

Reducing Disruptive Behaviors

Over a third (36%) of studies reviewed were designed to reduce behaviors disruptive to a child’s ability to participate or that interfered with other children’s participation.

Aggressive Behavior.

In four studies, the targeted behaviors included reducing physically aggressive behaviors such as grabbing, touching, or pushing in the classroom and generally reported positive findings. For example, pushing incidents were reduced for children 6-to-9 years old (n=3) (Mancil et al., 2009). Similarly, Aboulafia (2012) and Quilty (2007) noted a decrease in physically aggressive behaviors like grabbing, hitting, and kicking. Anderson et al. (2016) also found that physical aggression diminished, yet generalizability was not evident for all participants.

Sitting Inappropriately.

Classroom management is a critical component that many teachers address to create a successful educational experience. Motivating a child to sit in their chair appropriately is a concern expressed by many teachers because students who do not remain seated often distract others. Social narratives have been used to increase sustained attention, as demonstrated by sitting attentively in a chair. However, the findings are inconsistent. In six studies, researchers explored whether social narratives reduced “out-of-seat” behavior; four were effective (Chan, 2010; Chan et al., 2011; Graetz et al., 2009; Ozdemir, 2008), while two reported inconsistent outcomes (Aboulafia, 2012; Okada et al., 2008).

High-Pitched Vocalizations.

Crying, screaming, and loud vocalizations can disrupt occupational engagement. Results in 7 of 8 studies showed that social narrative interventions were effective in reducing vocalizations (Aboulafia, 2012; Abraham, 2009; Beh-Pajooh et al., 2011; Chan & O’Reilly, 2008; Graetz et al., 2009; Hung & Smith, 2011; Ozdemir, 2008), with Okada et al. (2008) being the exception.

Attention Seeking, Uncooperative, Off-Task Behaviors.

Reduction of behaviors considered attention seeking, uncooperative, or off-task (e.g., wandering in the classroom, laying on the desk) were addressed in 13 studies. Crozier and Tincani (2007) found social narratives to help reduce the frequency of off-task behaviors in a school setting. Cihak et al. (2012) found that task engagement only improved with youth 11-to-14 years (n=4) after watching the video social narratives that matched their specific behavior. Similarly, several authors found that social narrative interventions were effective when they targeted a specific off-task or uncooperative behavior (Alzyoudi et al., 2016; Perry, 2011; Quilty, 2007; Samuels & Stansfield, 2012). While more than 50% of the studies were positive, the authors of three reported inconsistent results (Beh-Pajooh et al., 2011; Krasch, 2014; Nasr, 2015), and four reported that social narratives were ineffective (Aboulafia, 2012; Doss, 2013; Kokina, 2012; Watts, 2008).

Inappropriate Comments/Verbal Protests and Actions.

The outcomes targeted in five studies were inappropriate comments or verbal protests, while the additional two focused on actions. Four of five researchers found that social narrative interventions effectively reduced perseverative commands, negative comments, and inappropriate laughter. Using a multiple baseline design, Quilty (2007) found that social narrative interventions decreased the disruptive behavior of repeatedly saying “go home” during class. Further, social narratives effectively decreased inappropriate comments, excessive direction-giving, noncontextual laughter, and negative comments (Chan, 2010; Dodd et al., 2008; Pane et al., 2015). Conversely, Aboulafia (2012) found inconsistent results for calling out in protest. Inappropriate actions such as putting objects in the mouth, placing hands in pants, or clinging to another person (Beh-Pajooh et al., 2011; Graetz et al., 2009) presented mixed findings such that social narrative interventions were effective for some but not all participants across the various behaviors.

Increasing Desired Behaviors

Whereas the previous section discussed disruptive behavior, this section examines social narratives used to enhance prosocial behavior and to facilitate performance.

Communication.

The focus of 20 articles revolved around improving communication, including social initiations and greetings, through nonverbal and verbal means. Social narrative interventions were effective for increasing social communication in individuals with ASD (Abraham, 2009; Acar et al., 2017; Anthony, 2015; Bricker, 2016; Doody, 2012; Gikas, 2013; Halle et al., 2016; Kagohara et al., 2012; Karayazi et al., 2014; Leaf, 2011; Olçay-Gül & Tekin-Iftar, 2016; Quirmbach et al., 2009; Reichow & Sabornie, 2009; Scattone, 2008). Litras et al. (2010) found that the desired behaviors of greeting, inviting to play, and contingent responding increased following the intervention and generalized to different settings, toys, and communication partners. In comparison, inconsistent results were found in some studies (Hutchins & Prelock, 2013; Krasch, 2014; Nasr, 2015; Sansosti & Powell-Smith, 2008), and others found little to no effect (Hanley-Hochdorfer et al., 2010).

Eye Contact.

The target of five studies, through social narrative interventions, was eye contact, three for adolescents ages 16-to-19 years old (O’Handley et al., 2015) and two for school-age children (Chan, 2010; Scattone, 2008). However, Cowan (2016) found that participation in a musically adapted social narrative did not increase eye contact. Aboulafia (2012) reported inconsistent results for a small group (n=7) of 5-year-old students; the authors reported that when the focus of the social narrative interventions was to increase eye contact, they were not effective, but when the goal was to reduce inappropriate eye contact, social narrative interventions seemed to be more effective.

Attending/On Task Behaviors.

Attending to a task is a necessary foundational skill to participate in various occupations successfully. Of the eight studies whose researchers tested whether social narrative interventions were effective at increasing attention, most (63%) were effective. Many of the researchers attempted to increase this behavior during class time (Aboulafia, 2012; Chan, 2010; Chan et al., 2011; Perry, 2011), while Schneider and Goldstein (2010) found that social narrative interventions were effective for increasing on-task behavior when preparing to leave class for the day.

With varying results, Anthony (2015) and Vandermeer et al. (2015) utilized Social narrative interventions via iPad to improve on-task behaviors and attention to materials or their teacher. Using the Percentage of Non-Overlapping Data scores, a non-regression approach to calculating effectiveness in single-subject design studies (Kratochwill et al., 2010; Scruggs & Mastropieri, 1998), Kokina (2012) demonstrated that social narrative interventions were ineffective in increasing targeted behaviors of 9-to-11-year-old children (n=3) in a school setting.

Play.

Play is a primary occupation for children that significantly contributes to their development. Social narrative interventions were utilized in three studies to increase aspects of play, including sharing, engagement, utilizing novel toys, adhering to rules, and turn-taking. Social narratives were found to be effective at increasing appropriate gameplay, specifically sportsmanship and the ability to follow the rules of games (Dodd et al., 2008; Jeekratok et al., 2014). Quirmbach et al. (2009) found that a standard format of social narrative and a directive story (an explicit description of expected behavior) were equally effective in eliciting, generalizing, and maintaining the targeted social skills (i.e., requesting to play a game, accepting another’s choice).

Self-Care.

Feeding and hygiene are essential self-care categories that impart a sense of independence and demonstrate adherence to social norms. Various aspects of self-care were addressed in two studies. In a unique study, Klett and Turan (2012) found that through social narrative interventions, participants could independently complete their bathroom routine, including independently changing their sanitary napkins. Similarly, social narrative interventions effectively reduced spills during meal times and the child’s ability to wipe their nose (Karayazi et al., 2014).

Social Interactions/Engagement.

Social interactions and social engagement (as described by researchers), distinct from social initiations, included maintaining conversation, engaging others in conversation while completing an additional task, and responding to peer initiation. The results of 9 of 15 studies showed an increase in social interactions (Dodd et al., 2008; Doody, 2012; Hillman, 2011; Kassardjian et al., 2014; Leaf, 2011; Ozdemir et al., 2008; Sansosti & Powell-Smith, 2008; Thompson & Johnston, 2013; Wright & McCathren, 2012).

Aboulafia (2012) found social narrative interventions to be effective overall for eliciting prosocial behaviors (e.g., sharing, cooperating) but not for prosocial interactions (e.g., talking nicely in class). Inconsistent results were found in four additional studies, such that targeted behaviors increased for some and remained unchanged for others (Ashmeade, 2017; Cowan, 2016; Hutchins & Prelock, 2013; Nasr, 2015). In one study, social narratives were ineffective at increasing social interactions (Samuels & Stansfield, 2012).

Identify Self and Emotions.

The three studies where researchers targeted the identification of emotions and self (e.g., recognizing name) all resulted in increased performance. Acar et al. (2017) utilized social narrative interventions to help with the identification of self and emotions, while the results of other two studies demonstrated that social narratives were effective in helping children first to recognize emotions in themselves and others and then learn how to respond appropriately (Bernad-Ripoll, 2007; Jeekratok et al., 2014).

A companion behavior to identifying emotions is the ability to express them appropriately. The target of three studies was to increase the display of emotive facial expressions through social narrative interventions. Olçay-Gül and Tekin-Iftar (2016) reported that social narrative interventions helped individuals with autism to express happiness. However, the use of social narratives to increase smiling was inconsistent (Cowan, 2016) or ineffective (Scattone, 2008).

Executive Functions.

Executive functions are the skills that enable humans to plan, organize and make decisions to complete tasks (Cermak & Toglia, 2018). Social narrative interventions were used to increase executive functions in five studies. In a multiple baseline study with preschoolers, Darley (2014) found that social narrative interventions increased children’s ability to demonstrate early executive function behavior, such as implementing the steps required to initiate joint attention with peers. Additionally, social narratives helped the individual to develop decision-making skills (Acar et al., 2017) and increase the ability to arrange and organize belongings in the classroom (Al zyoudi et al., 2016; Jeekratok et al., 2014). However, Kokina (2012) did not find social narrative interventions were effective in helping children 9-to-11 years old (n=3) organize themselves in preparation for school transitions.

Following Directions/Asking Permission.

Social narrative interventions to increase direction compliance and to ask for permission in six studies. Specific behaviors included asking permission at lunch, following the teacher’s instructions during circle time, and working independently. Social narrative interventions were effective in increasing these behaviors in all studies (Chan, 2010; Chan et al., 2011; Olçay-Gül & Tekin-Iftar, 2016; Ozdemir, 2008; Schneider & Goldstein, 2010; Thompson & Johnston, 2013).

Discussion

This scoping review highlights how social narrative interventions are used with individuals with ASD, which behavior change outcome measures are targeted and evaluated, and the research designs used. Outcomes targeted for behavior change included: aggression, inappropriate sitting, vocalizations, attention seeking, verbal protests and communication, eye contact, attending, game-play, self-care, social interactions, identification of self, executive function, and following directions. In this review, more of the social narrative interventions attempted to increase desired behaviors (nine subcategories) than to reduce disruptive behaviors (five subcategories). Increasing desired behaviors seemed to be more effective than extinguishing disruptive behaviors. Across the studies, the strongest findings seemed to be those which targeted aggressive behaviors, high pitched vocalizations, eye contact, play, self-care, identification of self and emotions, executive functions, and following directions/asking permission.

The majority of the studies in this review used social narrative interventions to address social skills behaviors. Approximately 33% of the articles focused on communication including social initiations and greetings, through nonverbal and verbal means. Social narrative interventions that attempted to improve behavior outcomes related to social engagement and prosocial skills such as recognizing emotions, initiating social contact and communication skills were generally supported.

In addition, social narratives were found to be effective at increasing appropriate gameplay, specifically sportsmanship and the ability to follow the rules of the game, and could be used to enhance the play skills of younger children. While limited, social narratives used to increase activities of daily living were found to be effective. This research gap may be a fruitful area for OTs to explore as the incorporation of a social narrative to reinforce daily living skills into a treatment program may be easily implemented.

Social narrative interventions were conducted in a variety of settings, including the home, school, medical and community facilities. Most of the interventions occurred in a school setting, as such, it is reasonable to assume that this is why the majority of the participants were also school-aged or adolescents. However, it is important to consider if there are any limitations or barriers related to the format or development of a social narrative that does not lend itself to an older population. For example, only two articles looked specifically at improving adult behavior outcomes, indicating a gap in the literature for this group.

While social narratives are highly adaptable and can be implemented effectively with very few resources required, it is crucial to examine not just whether an intervention works but for whom it is effective, under what circumstances, and for which behaviors - to understand the best practices for this population. The most robust findings were those implemented in school and community settings. This could result from training researchers and educators have in implementing social narrative interventions. However, of the few interventions that occurred in the home, most of them were found to be effective. Therefore, there is some promise that utilizing social narratives in to prepare for treatment and support behavior change may be of service as a resource for families, paraprofessionals, and pediatric occupational therapists. Specifically in early intervention or school settings where collaboration is so frequently demanded. The fact that they are highly adaptable, and there is some evidence that educators are familiar with it may be something that an OT can implement in therapy and get carryover from the classroom teacher.

Nearly all of the studies included in this review were single-subject research designs, and approximately two-thirds of the studies reviewed reported some positive effects of social narrative interventions. However, suggestions for future research involve increased use of stronger research designs such as randomized controlled trials (RCT), examination of the format in which the information is presented (e.g., video or storybook format), the similarity of the child in the story to the recipient of the story (e.g., sex, race, age), and whether the story is individualized with the recipient’s picture. Investigating child characteristics such as cognitive ability, sensory sensitivity, and attention, or variables, such as who delivers the intervention, and the frequency or duration (number of repetitions of the social narrative), are also important variables to examine. In addition, it would be nice to see an updated systematic review that examines the utilization of social narratives for those on the autism spectrum from an occupational therapy framework (i.e., occupation, performance skills, and client factors).

Limitations.

Although much of the literature suggests that social narrative interventions can have positive effects, there are several limitations. Most studies used a single-subject design with small sample sizes making results difficult to generalize. However, through replication, functional relationships can be determined (Kratochwill et al., 2010). There was only one RCT among the studies (Quirmbach et al., 2009). Another concern is that the fidelity measures of Social Stories were only sometimes employed and utilized, even when the authors stated they were using Social Stories. Thus, it was only sometimes possible to determine the validity of the social narrative interventions, primarily when the stories were not published as part of the article. It is also important to acknowledge that there is significant variability in the design of the interventions, which may make it hard for some to compare. This is a consideration for future research. We also acknowledge that methods of analysis varied among studies, and there was no agreement about the most methodologically sound approach to analyzing single-subject research design and comparing findings across studies (Heyvaert et al., 2014). Some studies used visual analysis, others used regression approaches, and others used non-regression approaches. Another critical element that needed to be addressed was the examination of maintenance and generalization.

Conclusions

Social narratives are a frequently used intervention to address behavior change for individuals with autism. Nevertheless, for many outcomes, equivocal results persist. However, that does not mean that the use of social narratives is without merit. Social narratives promote skills and behaviors in individuals with ASD to enable participation, an important goal in occupational therapy practice. They are an accessible and feasible intervention that can be implemented in various settings for a variety of behaviors, with particular consideration for whom it is effective and under what circumstances.