Social Stories to Improve Social Skills in Children with Autism Spectrum Disorder: a Systematic Review

Background: Over the past 20 years a variety of treatment approaches have been developed for and applied to children with Autism Spectrum Disorders (ASD) to remediate the core deficits. Since the early 1990s, Social Stories have been suggested to positively affect the pro-social development of children with ASD and much effort has been made to justify their expanded use.

Objectives: Our objective was to conduct a systematic review of the literature on the efficacy and effectiveness of Social Stories in the treatment of autistic children.

Methods: Using pre-defined, rigorous methods, two reviewers independently screened articles for inclusion, applied study eligibility criteria, extracted data, and assessed methodological quality. Results: A qualitative analysis was conducted on six eligible controlled studies.

Table 1: Overview of Study Objectives, Design, and Sample Characteristics
Study	Objective(s)	Design	Sample Characteristics
			Sample size (% males)	Age range, years (mean)	Description/severity of autistic symptoms	Diagnostic criteria (independently confirmed)
Andrews 2004	To increase game playing skills, story comprehension, and social skills comprehension	RCT (parallel)	20 (NR)	8-12 (10)	Severity not reported; children were verbal and could read and understand written words at or above first grade level	DSM-IV-TR, ADOS-G (NR)
Bader 2006	“To increase emotion recognition and labeling skills”	RCT (crossover)	20 (NR)	6-13 (9)	Severity not reported; children were verbal and could read and understand written words at or above kindergarten grade level	DSM-IV-TR, ADOS (NR)
Feinberg 2001	To increase four specific social skills during game playing	RCT (parallel)	34 (74%)	8-13 (10)	Moderately severe symptoms; children had at least phrase speech	DSM-IV, ADOS-G, ADI-R, GARS (NR)
Quirmbach 2006	1) To increase game playing skills and story comprehension; 2) to compare different story formats; 3) to assess children’s ability to generalize and maintain skills	RCT (parallel)	45 (93%)	7-14 (??)	Children could read at or above first grade level; 42/45 children diagnosed with autism and 3 with ASD	DSM-IV-TR, ADOS (NR)
Ricciardelli 2006	To improve five specific pro-social behaviors	CCT (parallel)	6 (100%)	10-13 (11)	Cognitive levels average to low average; some verbal skills present	NR
Romano 2002	To reduce inappropriate communication, aggressive behaviour, and inappropriate socialization behaviours	CCT (parallel)	10 (50%)	4-8 (6)	Children able to communicate (express wants and needs) either verbally or non-verbally (i.e., augmentative device, manual communication board, sign language, modified sign language, gestures)	NR
RCT=randomized controlled trial; CCT=controlled clinical trial; NR=not reported

Conclusions:  Of the six unpublished controlled trials (four RCT, two CCT) evaluating the effect of Social Stories on ASD patients, five (four RCT and one CCT) concluded that social stories are effective in terms of decreasing aggressive behavior, improving communication and socialization skills, teaching social skills, increasing game playing skills, enhancing comprehension and generalizing social comprehension, and increasing facial emotion learning and labeling. One study also demonstrated that both standard and directive story formats can be equally effective in eliciting game play skills.