J. Indian Assoc. Child Adolesc. Ment. Health 2015; 11(3): Case Report

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1 246 J. Indian Assoc. Child Adolesc. Ment. Health 2015; 11(3): Case Report Social Story in Improving Problem Behavior in Moderate Autism A Case Study Sakshi Rai, S. Haque Nizamie, Alka Nizamie Corresponding author: Sakshi Rai, Assistant Professor, Department of Clinical Psychology, Central Institute of Psychiatry, Kanke, Ranchi , Jharkhand. Contact No Abstract Social cognition in autism spectrum disorder is important domain which is needed to work upon through various means. Social stories (SS) are a tool in hand to target such domain. The present study aims to assess the efficacy of social stories in improving problem behavior in autism spectrum disorder by examining its qualitative and quantitative changes along with its maintenance effect under 2-months follow-up by using ABA design, conducted over a nine year old boy with a diagnosis of atypical autism with moderate social and developmental delay. Behavior was improved on few domains with the use of social stories, although the sustainability of behavior after 2 months follow up could not be maintained on all sub domains Key words: Social story (SS), Autism spectrum disorder, Cognition, Problem behavior

2 247 Introduction Autism spectrum disorder (ASD)as mentioned by Cohen et al [1] encompasses varied as well as substantial social, communicative and behavioral problems. Lorimer et al [2]and Rust [3] have reported effectiveness of SS in reducing tantrum behavior, enhancing interpersonal conflict in learning disability, also in improving meal time skills in Asperger s but it is also often used in combination with several other behavioral techniques like verbal prompt or by adding other reinforcement values. It yields best result in higher functioning autism. Present study attempts to understand the effect of SS along with child s own picture depicting desirable response in case of moderate level of developmental and social functioning with mild to moderate autism. The child was a nine years old boy, who was born out of full term normal vaginal delivery without any pre-postnatal complication. Although his parents were able to understand that there were something wrong with their child in preschool age, and consulted a psychiatrist only at 6 years of age and he was diagnosed with atypical autism. Simultaneously he was referred to the special school Deepshikha Institute of Child Development and Mental Health, and recruited for study. Psychological assessment revealed that the child has mild to moderate autism, moderate level of impairment in socio-adaptive and developmental functioning. Problem behaviors were identified using checklist which were touches things without asking, stubbornness, and destroys things. Out of mentioned behavior the first behavior was targeted through social story considering its objective interference in school set up as well as rated as most severe by therapist, parents and special educator (co therapist). The targeted behavior was

3 248 topographically operationalized. Functional assessment of behavior is given in Table number-1. Social Story Intervention- Through SS attempt was made to make child understand the concept of asking or naming instead of snatching in class room setting. Snatching is described as taking object from the teacher as well as from the other student without asking or pointing to teacher. Pointing is physical indication towards the desired object while facing teacher. Story was written in a book format entitled Ankit in class room comprised of seven descriptive sentences, two perspective sentences and two directive sentences and one affirmative sentence with associated pictures of a child along with the sentences keeping self -reference of memory in view (See appendix -1 for details). Pictures were taken with consent of his parents in classroom natural setting where the desirable behavior is assumed to be manifested. One sentence was written over single A4 sized paper in Hindi language. It was assured that the story is read to the A.S in both school and home setting where the therapist and educator were present in school and parents in home. Story is told

4 249 to him three times a day in school where as in home setting he was told story at least once before going to bed by his mother. However, parents were free to read the story on demand made by the child. It was also ensured that the other behavioral interventions like prompting and time out for snatching are controlled in class room setting. Three sessions were taken by therapist and co-therapist every day, lasting for nine to ten minutes each in a single classroom setting; however, it varied in home setting. Intervention continued for ten consecutive days. In total 30 sessions were taken in class. Data was obtained under four intervals that is 1) Pre-intervention phase/ Baseline recording 2) Intervention phase for 10 days (30 sessions in class + 10 sessions in home) 3) Post intervention namely 1 month and 2 months F/up All the recordings were obtained by dividing frequency of behavior displayed against number of events, in terms of percentage. See table number 2 for the differences in score across 4 readings in frequency recording in terms of percentage.

5 250 Discretely a downfall is noted after 40 sessions in desirable behavior learned. However, it is worth noticing that intervention helped reducing the occurrence of undesirable behavior for at least 40 sessions. Regarding leaving seat, there is a post intervention significant decrease by 67 percent is seen, however the improvement did not continue by the end of first and second month follow up. With respect to the snatching behavior A S has shown remarkable improvement over the four readings, as it has gone down from baseline of around 67 percent to 42 percent post intervention and has not peaked up to baseline in follow ups. Under desirable behaviors, the pointing after 40 sessions increased up to 38 percent and subsequent rise 41 and 43 percent in first and second month follow up respectively. Whereas the naming also improved from 34 percent to 40 percent post intervention. Interestingly naming continued improving after one month follow up as well by 43 percent but has gradually declined by 39 percent by second month follow up. In the lines with the previous researches, present study found a little change in behavior to modify with respect to moderate delay in developmental as well as social functioning. Although it is true that story did help in bringing change particularly in nonverbal domain of pointing over a period of 2 months follow up. However, it also suggests that the efficacy of social story is mostly confined to the time frame of the intervention. It suggests that intervention is needed for a long duration to prolong the effect. As the behavior has shown little improvement during an intervention but has markedly reduced as it has not been consistently practiced. The findings suggest that the

6 251 social story in particular has not been found very efficacious that is, within an experimental condition (B) it has shown a significant effect over the behavior. Overall it entails that the behavioral manifestation of the problem cannot solely be targeted through SS, it needs the extended measures as well to ensure the progress in the behavior. It is stated that the SS work better with the higher functioning autism, which takes into account two basic criteria namely verbal skills and intelligence. As the assessment of the child suggests that the child falls under the moderate level of retardation in social as well as developmental functioning, along with moderate disability, it can be stated that these measures could be the reason for the failure of maintenance of treatment. For the maintenance of the treatment it is indeed needed to be attached with other interventions and may for a longer duration to register the cues of socially appropriateness in the child s behavior repertoire. The major limitation of social story is its narrow focus. The stories are difficult to be generalized in different settings. As mentioned by Rust [3] regarding several general factors that need be addressed when evaluating the use of SS. Efficacy versus effectiveness is one of the major issues. SS are an intervention used to help children understand and behave appropriately in specific social situations. Therefore, it is important that their usefulness is measured in the environment in which behavioral changes are intended. Lengths of the sessions, number of sessions, reading ability of the child, co-morbid conditions are all important intervening variables. Stories whether read out by the student or by the caregiver seem to have important bearing. The influence of these factors on the success of SS requires more systematic investigation. Most of the studies reviewed operationally defined behaviors

7 252 for example; Norris & Dattilo [4] define what constitutes appropriate, inappropriate and absence of social interaction. Whilst a decrease in an inappropriate behavior may seem to be indicative of success but it does not necessarily imply that an appropriate alternative behavior has developed. However, in present study it can be seen that there is an increment in desirable behavior that is naming and pointing. In present study also the settings are attempted to increase than one by including the instructions in stories read back at home but the recording of behavior was not set to school as it was not covered in the story as well. While Kuttler et al [5] considered possible factors resulting in problems for the child (e.g. lack of structure and change), SS used was found incorporating rewards than explanation to direct the child. Similarly, various researches have used the SS along with behavioral intervention as response cost, prompting etc. which further complicates the role of SS alone. Conflict of Interest None declared. References 1. Baron-Cohen S, JolliffeT, Mortimore C, Robertson M. Another Advanced Test of Theory of Mind: Evidence from Very High functioning adults with autism or Asperger syndrome. J Child Psychol Psychiatry ;

8 Lorimer PA, Simpson RL, Myles BS, Ganz JB. The use of social stories as a preventative behavioral intervention in a home setting with a child with autism. J Posit Behav Interv ; RustJ.How should the effectiveness of Social Stories to modify the behavior of children on the autistic spectrum be tested? Lessons from the literature. Autism2006;10(2): NorrisC, Dattilo J. Evaluating the Effects of a Social Story Intervention on a Young Girl with Autism. Focus on Autism and Other Developmental Disabilities. Focus Autism Other Dev Disabl 1999; 14 (3): KuttlerS, Myles BS, CarlsonJK. The Use of Social Stories to Reduce Precursors to Tantrum Behavior in a Student with Autism. Focus Autism Other Dev Disabl (3): Sakshi Rai, Assistant Professor, Department of Clinical Psychology, Dr S. Haque Nizamie, Professor of Psychiatry, In-charge of Center of Cognitive Neurosciences, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, Dr. Alka Nizamie, Director Academics, Deepshikha Institute of Child Development and Mental Health, Ranchi, Jharkhand

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