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JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2012, 45, 281–298 NUMBER 2 (SUMMER 2012)

COMPARING THE TEACHING INTERACTION PROCEDURE TO SOCIAL STORIES FOR PEOPLE WITH AUTISM

JUSTIN B. LEAF, MISTY L. OPPENHEIM-LEAF, NIKKI A. CALL, JAN B. SHELDON, AND JAMES A. SHERMAN

UNIVERSITY OF KANSAS

AND

MITCHELL TAUBMAN, JOHN MCEACHIN, JAMISON DAYHARSH, AND RONALD LEAF

AUTISM PARTNERSHIP

This study compared social stories and the teaching interaction procedure to teach social skills to 6 children and adolescents with an autism spectrum disorder. Researchers taught 18 social skills with social stories and 18 social skills with the teaching interaction procedure within a parallel treatment design. The teaching interaction procedure resulted in mastery of all 18 skills across the 6 participants. Social stories, in the same amount of teaching sessions, resulted in mastery of 4 of the 18 social skills across the 6 participants. Participants also displayed more generalization of social skills taught with the teaching interaction procedure to known adults and peers.

Key words: autism, behavioral skills training, social skills, social stories, teaching interaction

Autism spectrum disorders (ASD) are marked by qualitative impairments in social behavior (American Psychiatric Association, 2000) that can lead to failures in developing meaningful friendships (e.g., Bauminger & Kasari, 2000), depression (e.g., M. E. Stewart, Barnard, Pearson, Hasan, & O’Brien, 2006), and problems in school (e.g., Ladd, Birch, & Buhs, 1999). Over the past 30 years, a variety of methods have been implemented to teach social behaviors, including video modeling (e.g., Charlop-Christy, Le, & Freeman, 2000), discrete-trial teaching (e.g., Lovaas, 1981), pivotal response training (e.g., Stahmer, 1995),

Justin B. Leaf is now at Autism Partnership, Seal Beach, California, and Great Strides Behavioral Consulting, St. Louis, Missouri; Misty L. Oppenheim-Leaf is now at Behavior Therapy and Learning Center, Seal Beach, California.

This investigation was conducted to meet, in part, the requirements for the doctoral degree in Behavioral Psychology at the University of Kansas. We thank Sarah Johnson for her work throughout the project. We also thank Keith Miller, Nancy Brady, and Matthew Reese for their help on an earlier version of this study.

Correspondence concerning this article should be addressed to Justin B. Leaf, 200 Marina Drive, Seal Beach, California 90807 (e-mail: [email protected]).

doi: 10.1901/jaba.2012.45-281

behavioral skills training (e.g., K. K. Stewart, Carr, & LeBlanc, 2007), social stories (e.g., Gray & Garand, 1993), and the teaching interaction procedure (e.g., Leaf et al., 2009). Despite the numerous interventions to help people with ASD improve their social skills, relatively few studies have compared these different interventions.

Social stories are brief passages, written by a teacher, that describe a behavior to be displayed by a participant. The story describes when the participant should display the desired behavior, why he or she should display the desired behavior, and how displaying the desired behavior will affect others (Gray & Garand, 1993). Teachers either read the stories aloud to the students or students read the stories to themselves or out loud. In some studies, the teacher either asked the participant comprehen- sion questions (e.g., Delano & Snell, 2006) or role-played the social skill with the participant (e.g., Thiemann & Goldstein, 2001) after the participant read the story.

Gray and Garand (1993) and Gray (1994) provided several guidelines related to the implementation of social stories to teach social

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skills. First, participants should be in the ‘‘trainable mentally impaired range or higher who possess basic language skills’’ (Gray & Garand, p. 2). Second, the teacher should write an individualized story at the participant’s comprehension level. Third, social stories should include four sentence types: descriptive sentences that specify when, where, and why the participant should display the desired social behavior; perspective sentences that describe the reactions and feelings that others may have if the participant displays the social behavior; affirmative sentences that describe a shared belief of society; and directive sentences that specify how the participant should display the behavior. Gray (1995) recommended a total of two to four descriptive, affirmative, or perspec- tive sentences for every directive sentence in the story. Subsequent research on social stories has evaluated several presentation variations, in- cluding the use of pictures or icons (e.g., Barry & Burlew, 2004; Brownell, 2002), different story layouts (e.g., book format or single-page format), role playing (e.g., Thiemann & Gold- stein, 2001), and comprehension checks (e.g., Delano & Snell, 2006), and found each to be effective.

The teaching interaction procedure is anoth- er method to teach social skills to children with autism. In the teaching interaction procedure, the teacher describes a skill, provides a rationale for why the participant should display the skill, describes the cues and characteristics of situa- tions in which the participant should display the skill, divides the skill into smaller behavioral components, models the skill, and role plays the skill with the participant. During role playing, the teacher provides simulated opportunities for the participant to display the social skill and provides feedback (e.g., praise, tangible conse- quences, or corrective feedback) based on the participant’s performance.

The teaching interaction procedure first was implemented and evaluated as a component of the Achievement Place Teaching-Family Model

(Phillips, Phillips, Fixsen, & Wolf, 1971, 1974). Subsequent research has demonstrated the effectiveness of this strategy in both one-on-one (Leaf et al., 2009) and group (Leaf, Dotson, Oppenheim, Sheldon, & Sherman, 2010) teach- ing arrangements. In addition, the teaching interaction procedure is similar to another well- researched procedure, behavioral skills training; the main difference between the two is the inclusion of rationales in the teaching interaction procedure (K. K. Stewart et al., 2007).

Thus, available evidence indicates that both social stories and the teaching interaction procedure are effective methods for teaching social behaviors to children and adolescents with ASD. However, the relative effectiveness of the two procedures is unknown, in that no direct comparison of these teaching strategies have been conducted to date. This study was designed to compare these two interventions. We selected these two procedures because they both have been implemented with numerous children and adolescents with autism, share common components, and have been found to be effective in the empirical research. The purposes of the current study were (a) to assess the relative effectiveness of the two procedures in teaching social skills to children and adolescents with ASD and (b) to assess the level of generalization of the social skills taught by each method.

METHOD

Participants Six boys, ages 5 to 13 years old, were

recruited to participate in this study. Each participant met the following criteria: (a) He had been diagnosed with an ASD; (b) he spoke in full sentences; (c) he had no immediate history of self-injury, severe aggression, or severe disruptive behaviors; and (d) he had a standard score of 70 or higher (i.e., within two standard deviations of the average range and considered to be a moderately low score) on the Peabody Picture Vocabulary Test 4 (PPVT-4).

283 COMPARING SOCIAL SKILLS INTERVENTIONS

Buddy was a 6-year-old boy who had been diagnosed with autistic disorder. The PPVT-4 placed him in the 27th percentile of receptive language with a standard score of 91 (6 years 1 month age equivalent). He had a Mullen’s intelligence score (IQ) of 87, and a Social Skills Rating Scale-Parent (SSRS-P) score of 69 (2nd percentile of children his age). Buddy attended a general education kindergarten classroom without supports and previously had been taught with both social stories and the teaching interaction procedure prior to this study.

Hank was a 5-year-old boy who had been diagnosed with pervasive developmental disor- der not otherwise specified. The PPVT-4 placed him in the 97th percentile of receptive language with a standard score of 128 (8 years 3 months age equivalent). He had a Wechsler Intelligence Scale for Children (WISC IV) IQ score of 117, a SSRS-P score of 91 (27th percentile of children his age), and a Vineland Adaptive Behavior Composite score of 87. He attended an early intervention clinic for children with ASD and had a prior history with both social stories and the teaching interaction procedure.

Nick was a 5-year-old boy who had been diagnosed with autistic disorder. The PPVT-4 placed him in the 8th percentile of receptive language with a standard score of 79 (3 years 11 months age equivalent). He had a Kaufman IQ score of 65, a SSRS-P score of 70 (2nd percentile of children his age), and a Vineland Adaptive Behavior Composite score of 68. He attended a general education kindergarten classroom without any supports and had a previous history of being taught with social stories but not with the teaching interaction procedure.

Lang was a 5-year-old boy who had been diagnosed with Asperger syndrome. The PPVT- 4 placed him in the 61st percentile of receptive language with a standard score of 104 (5 years 11 months age equivalent). He had a Wechsler Preschool and Primary Scale of Intelligence (WPSSI-3) IQ score of 89, a SSRS-P score of

106 (66th percentile of children his age), and a Vineland Adaptive Score of 85. He had been placed in a general education kindergarten classroom setting with supports and had a previous history of being taught with both social stories and the teaching interaction procedure.

Apollo was a 12-year-old boy who had been diagnosed with autistic disorder. The PPVT-4 placed him in the 47th percentile of receptive language with a standard score of 99 (12 years 1 month age equivalent). He had a WISC-IV IQ score of 80, and a SSRS-P score of 73 (4th percentile of children his age). He attended a general education sixth-grade classroom without supports and had a previous history of being taught with social stories but not with the teaching interaction procedure.

Mickey was a 13-year-old boy who had been independently diagnosed with autistic disorder, attention deficit hyperactivity disorder, and Tourette syndrome. The PPVT-4 placed him in the 73rd percentile of receptive language with a standard score of 109 (14 years 3 months age equivalent). He had a WISC IV IQ score of 82 and a SSRS-P score of 96 (39th percentile of children his age). He attended a general education junior high school (seventh grade) without supports and had a previous history of being taught with social stories but not with the teaching interaction procedure.

Setting One 45-min session was conducted 3 to

6 days per week, either in a research room at a midwestern university, at the participants’ homes (Lang, Apollo, and Mickey), or both (Buddy, Hank, and Nick). All teaching sessions and performance probes were conducted in the same location. Some of the generalization probes were conducted in the same location, and some generalization probes were conducted in other research rooms or in other rooms in the participant’s house. The research room at the university was 3 m by 1.5 m and contained a cabinet, two chairs, toys, and a one-way mirror that allowed the participants’ parents to observe

284 JUSTIN B. LEAF et al.

Table 1 Skills Taught

Participant Teaching Interaction Skill 1 Social Story Skill 1 Teaching Interaction Skill 2

Buddy Losing graciously (3 steps) Negotiation ( 4 steps) On-topic conversation (7 steps) Hank Sportsmanship (4 steps) Losing graciously (3 steps) Changing the conversation (4 steps) Nick Giving compliments (2 steps) Appropriate greetings (5 steps) Sportsmanship (4 steps) Lang Cheering up a friend (6 steps) Changing the conversation (4 steps) Losing graciously (3 steps) Apollo Showing appreciation (3 steps) Negotiation (4 steps) On-topic conversation (3 steps) Mickey Reciprocal compliments (5 steps) Providing assistance (3 steps) Losing or wining graciously (3 steps)

the research sessions. Sessions at the partici- pants’ homes took place in a living room or in a basement. Available items in the participants’ homes included a table, chairs, couches, cabinets, and entertainment equipment (e.g., television, video game consoles, DVD player).

Skills Taught The experimenter used parent answers on the

Social Skills Rating Scale (Greshman & Elliot, 1990), informal parental interviews, and direct observation of the participants to identify six social skills to be taught to each participant. Each social skill was divided into smaller steps, including a set of basic skill steps (e.g., face the person, look the person in the eye, have a relaxed body posture, use a neutral voice tone, smile, display no aggression, use no curse or nonsense words, and engage in no crying) and a varying number of skill-specific steps (e.g., providing a negotiation statement). Table 1 provides infor- mation on the number of skill-specific steps in each of the social skills taught (contact the first author for a listing of the skill steps).

Following social skill selection, the experi- menter then attempted to pair social skills together that had roughly the same number of skill steps, and randomly assigned (by a computer program) the skills either to the teaching interaction procedure or to the social stories procedure. In addition, if a particular social skill was taught to two different partic- ipants and the other skills being taught to the two participants were equivalent in number of steps, the particular social skill was taught using the randomly assigned procedure for one

participant and the other procedure for the other participant. Unfortunately, skills taught in the teaching interaction procedure for Buddy and Hank resulted in a greater number of steps. In addition, not all skills were taught with both procedures.

Dependent Measure The dependent variable was the percentage of

skill steps exhibited by the participant during performance probes with the experimenter, generalization probes with other known adults, and generalization probes with peers. Perfor- mance probes were conducted during baseline, intervention, and maintenance conditions (de- scribed below) to determine mastery of each of the social skills taught. The mastery criterion was defined as the participant displaying 100% of all skill steps correctly during performance probes for three consecutive sessions during intervention. If the participant reached the mastery criterion for one of the two skills, but did not reach mastery criterion for the third skill (e.g., a participant reached mastery crite- rion for a skill taught with the teaching interaction procedure but did not reach mastery criterion for a skill taught with social stories), teaching continued for the nonmastered skill until at least five additional teaching sessions for that skill and at least a total of 12 performance probes had been completed.

Generalization probes were conducted be- fore, during, and after the intervention (de- scribed below). Probes with other adults were conducted to determine whether participants would generalize the social skills to known

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Table 1. (Extended)

Social Story Skill 2 Teaching Interaction Skill 3 Social Story Skill 3

Sportsmanship (4 steps) Showing off work (4 steps) Making empathetic statements (3 steps) Explaining a prior ‘‘cool’’ event (4 steps) Losing or winning graciously (3 steps) Showing interest (7 steps)

Clarifying instructions (7 steps) Interrupting (7 steps) Changing the game (6 steps) Joining into a game (7 steps) Changing the game (6 steps) Changing the game (6 steps)

Changing the conversation(4 steps) Cheering up a person (6 steps) Showing appreciation (3 steps) Interrupting appropriately (7 steps) Disagreeing appropriately (6 steps) On-topic conversation (6 steps)

adults (e.g., parents or research assistants) who had not taught the various social skills. Generalization probes with peers were conduct- ed to determine if participants would generalize social skills to situations during which peers were present.

Design and General Procedure Design. A parallel treatment design (Gast &

Wolery, 1988) was used to evaluate the effectiveness of the two social skills interven- tions. Differences in effectiveness would be indicated if one of the teaching procedures reliably produced more behavioral change in a shorter time than the other teaching procedure. The study consisted of three phases: an initial baseline, intervention, and maintenance. Due to the nature of the design, during the interven- tion, some skills were being taught while other skills that had been previously taught were in the maintenance condition, and skills not yet taught were in the baseline condition. Perfor- mance and generalization probes took place during baseline, intervention, and following treatment.

Performance probes. During performance probes, the experimenter engaged in a behavior that set the occasion for the participant to display one of the social skills. Multiple exemplars (two or more) were used during performance probes, except for the skills of sportsmanship and cheering up a person. For example, for giving a compliment, the experi- menter showed the participant a picture that the experimenter had drawn or a photograph that the experimenter had taken and waited to see if

the participant would respond. After approxi- mately 1 min, the experimenter recorded which steps the participant displayed and which steps the participant did not display. No reinforce- ment or other consequences were provided during probes.

Generalization probes. Generalization probes with adults were similar to performance probes except that they were conducted with an adult who was not involved in teaching. The adults were instructed to use multiple exemplars (two or more) during generalization probes (except for the skills of sportsmanship and cheering up a person). During generalization probes with adults, there were no consequences for partic- ipant performance. Generalization probes with peers were the same as generalization probes with adults, except that peers conducted them. Peers were primed prior to the session on how to conduct probes, and the experimenter remained present during the probes to prompt the peer on when to initiate probes. The peers were instructed to use multiple exemplars (two or more) during generalization probes (except for the skills of sportsmanship and cheering up a person). For Mickey and Apollo, generaliza- tion probes with peers were conducted before and after the intervention. For Buddy, Nick, and Lang, these probes were conducted only after the intervention. No generalization probes with peers were implemented for Hank, because his family moved before they could be conducted.

Initial baseline. In the initial baseline, each session began with the experimenter imple- menting performance probes for each of the six

286 JUSTIN B. LEAF et al.

social skills to be taught. The order of the performance probes was determined randomly ahead of time. The probes were followed by a short 5-min break during which the participant played with toys or other items in the room. After this short break, a research assistant or the participant’s parent implemented generalization probes with adults for each of the six social skills. The order was determined randomly ahead of time.

After all six generalization probes with adults had been conducted for Buddy, Hank, Nick, and Lang, the session ended. However, Apollo and Mickey had another 5-min break, during which time they could play with toys or other items in the room. Following this short break, generalization probes were conducted with peers. The order of the generalization probes was determined randomly.

Intervention. Two social skills (one assigned to the teaching interaction procedure and one assigned to social stories) were taught while the other four skills were exposed to either the baseline or maintenance conditions. Each session began with the implementation of performance probes for both social skills that were currently being taught and for some of the other randomly selected social skills that were in either the baseline or maintenance conditions. The order of the performance probes for each skill was determined ahead of time. A 5-min break was provided after all of the performance probes were conducted. Participants were allowed to play with toys or other items during this break. After this break, the experimenter implemented one of the two teaching conditions (i.e., teaching interaction or social stories) followed by another 5-min break. After this break, the experimenter imple- mented the other teaching condition. The order of the two teaching conditions was selected randomly before each session. Following imple- mentation of both procedures, the session either was terminated or the participant had a 10- to 20- min break, during which he could play with toys or could interact with other people. Next, generalization probes with adults were conducted.

Maintenance. After the participant had reached the mastery criterion for a social skill, performance and generalization probes were periodically conducted during certain sessions. After the participant had reached the mastery criterion for all social skills, all three types of probes were implemented three more times.

Reinforcement procedures. Potentially reinforc- ing stimuli were selected for each participant prior to beginning the teaching conditions. These potential reinforcers were identified based on interviews with the participants’ parents and teachers and observations of participants in their natural setting. Stimuli included tangible reinforcers (e.g., bouncy balls or Whoopie cushions) and privileges (e.g., going outside to play or visiting a professor). A token economy was in place during the teaching conditions (see further description below). Participants did not earn tokens during any of the probe sessions. At the end of each session, participants could exchange tokens (i.e., tickets) for preferred items or activities. Partic- ipants could also save tickets across sessions to earn larger reinforcers (e.g., fountain pen or gift card). Reinforcement opportunities were equat- ed so that a participant had the possibility of earning the same amount of tickets for both teaching procedures within a given session. To equate the amount of possible tickets to be provided in the two conditions, we took the total amount of possible tickets that a partici- pant could earn in the social stories procedure (i.e., one ticket per page of the social story and four tickets for the four comprehension ques- tions) and provided the same amount of possible tickets in the teaching interaction procedure.

Teaching Procedure Teaching interaction procedure. First, the

experimenter made a statement (e.g., ‘‘Today we are going to talk about saying ‘hello.’’’) and then asked the participant to state the skill to be taught. If the participant accurately labeled the

287 COMPARING SOCIAL SKILLS INTERVENTIONS

skill within approximately 10 s of the instruc- tion, positive reinforcement was provided (i.e., tickets and praise [e.g., ‘‘Good job dude.’’]). If the participant did not label the skill correctly or did not respond within 10 s of the instruction, the experimenter provided correc- tive feedback (e.g., ‘‘You need to try.’’ or ‘‘That’s not it.’’) and repeated the sequence (i.e., labeling the targeted skill and asking the participant to repeat the skill) until the participant accurately labeled the skill. Next, the experimenter explained why the participant should engage in the behavior (e.g., ‘‘If I say ‘hello,’ my friends might ask me to play.’’), and asked the participant to state a rationale. The participant was given approximately 10 s to respond to the instruction and received the same consequences as described above. Then, the experimenter described times or situations in which it might be appropriate to display the skill (e.g., ‘‘I should say ‘hello’ when I see a friend for the first time.’’) and asked the participant to repeat the description. The participant was given approximately 10 s to respond to the instruction and received the same consequences as described above.

After the first teaching session of a new skill, the same procedures were used, except that the experimenter simply asked the question (e.g., ‘‘What skill are we going to talk about today?’’) without providing the model of the correct response. The participant was given 10 s to respond and received positive reinforcement (i.e., tickets and praise) if he responded correctly (e.g., ‘‘saying ‘hi’’’). If the participant did not respond within 10 s or responded inaccurately (e.g., ‘‘saying ‘bye’’’), the experi- menter provided corrective feedback (e.g., ‘‘That’s not it.’’) and repeated the question. If the participant responded correctly on this remedial instruction, positive reinforcement was provided (i.e., tickets and praise). If the participant responded inaccurately or did not respond within approximately 10 s, the exper- imenter again provided c