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Section 14
Social Referencing in Children with ASD

Question 14 | Test | Table of Contents

Children with Autism Spectrum Disorder (ASD) have difficulty attending to social cues and experience problems in interpreting such stimuli. In addition, they have difficulty in (a) understanding the beliefs of others, (b) shifting attention, (c) sharing attention with others, and (d) distinguishing relevant from irrelevant stimuli. The relevance of attending to and understanding social cues is imperative because an understanding of the world most often comes from others' verbal cues, gestures, facial expressions, and so forth (Attwood, 1998; Myles & Simpson, 1998).

Gray (1995a, 1995b) developed two visual systems-social stories and comic strip conversations--that are designed to illustrate and interpret social situations and provide support to "students who struggle to comprehend the quick exchange of information which occurs in a conversation" (p. 2). These techniques turn an abstract situation into a concrete representation that allows for reflection. Social stories use a brief narrative that describes a situation, relevant social cues, and responses. Comic strip conversations promote social understanding by incorporating simple figures and other symbols in a comic strip format. An educator can draw or assist a student who illustrates a social situation in order to facilitate understanding.

Limited research exists on social stories. In fact, only four studies have been published on the effectiveness of this technique (Hagiwara & Myles, 1999; Kuttler, Myles, & Carlson, 1998; Norris & Datillo, 1999; Swaggart et al., 1995). Although the use of comic strip conversations has been reported anecdotally, to date no research has been published demonstrating the impact of this technique. The purpose of this article is to overview the use of social stories and comic strip conversations with a young man with ASD.

Tom: An Adolescent with ASD
Tom was a 14-year-old student diagnosed by a licensed psychologist as having ASD. He was an eighth-grade student who experienced learning difficulties and struggled with maintaining attention to task.

Tom saw himself as having many friends across both general and special education settings, many of whom he considered to be best friends. Even though the majority of his general "friends" did not know his name or interact with him, Tom still felt he was an integral part of their social group. He did, however, interact with several students with special needs, although these interactions were not always pleasant. He had voiced distress over the "spats, bad words, and hurt feelings" that surrounded his relationships with these students.

Although Tom exhibited some degree of behavioral problems throughout the day, resource room teachers reported that his behavior appeared to escalate immediately following lunch and was maintained during physical education (PE), his first class after lunch. They described his behavior as confused. After lunch he would walk to his locker making facial grimaces, flapping his hands, and talking to himself. When he reached his locker, he would pace back and forth in front of it. The teachers reported that he needed several verbal or physical prompts to open his locker or gather materials for PE. Even with these prompts, Tom was often late to class, and his PE teacher noted that he appeared "agitated and unable to focus."

Social Stories and Comic Strip Conversations
The resource room teacher who assisted Tom with his academics attempted to talk with Tom about his behavior and tardiness in several one-on-one meetings. Discussions of his behavior seemed disjointed and confused; Tom was concerned about lunch with his friends, particularly girls. He reported that the girls were "making fun" of him. In addition, Tom voiced that he was bothered by the conversation topics that occurred in his presence. He did not appear to have any strategies to change his behavior and, in fact, thought that his peers should be arrested for these behaviors. His conversations with his resource room teacher appeared to result in little change in his behavior.

After five individual meetings, a social story was introduced to Tom that outlined what occurred during lunch and the steps he was to follow to get from lunch to PE class. Tom read this story daily before lunch for 5 days. On the 10th day, the resource room teacher revised the social story to elaborate on some of the lunch activities and his movement from one activity to the next. Table 1 contains the two social stories that Tom read daily.

On the 12th day, Tom's resource room teacher introduced comic strip conversations. She spent approximately 15 minutes per day interpreting a social situation in a comic strip that Tom identified as problematic. Two samples of cartoons that Tom's resource center teacher drew to illustrate the social problems Tom experienced are included here. The first provides an example of a comic strip conversation that Tom's teacher used with him. This particular incident occurred when a girl told Tom that he had a "cute butt." The girl was attempting to tell Tom that she liked him. Tom, however, perceived the girl's comments as sexual harassment and replied in kind by calling the girl a sexist pig (see Figure 1).

The second shows Tom's attempt to talk to a friend by providing a compliment. Tom did not understand that the word he used ("preppy") held a negative connotation for his peers. His peer responded in a negative way; Tom offered a similar retort.

To determine whether the social stories and comic strip conversations were effective for Tom, his resource center teacher counted the number of verbal redirections that Tom needed to get to PE class, as well as the number of minutes he was late to class. Table 2 briefly describes her findings.

Tom's behavior changed. It was hypothesized that the comic strip conversations were most effective in helping Tom interpret social situations. He reported that he enjoyed using comic strip conversations and began to request their use from others at school and home. For example, on one occasion following the study, Tom asked another teacher to illustrate a social situation while they were sitting together on a bus during a field trip. He also began to ask his mother to draw comic strips for him. Thus, it appears that this technique helped Tom understand his social world.

Research is needed to validate whether and under which circumstances social stories and comic strip conversations are effective. These two interpretive techniques appear to hold promise for children and youth with ASD. They directly address an area of challenge seen in persons with ASD--interpreting social situations that are primarily verbal and that offer little reflection time. Both techniques are also potentially important because they are adult- and student-friendly and are designed to be used in the classroom, home, and community settings with no need for expensive tools or specially constructed environments.

Table 1: Teacher-Created Social Stories to Help Tom Transition From Lunch to Physical Education Class
Social Story 1
I eat lunch with my friends.
Sometimes we laugh and talk.
After lunch, I need to put my ID card away in my locker and get my notebook.
I need to get to PE class on time. will get to PE on time with my notebook.
I will get to PE on time before the bell rings.

Social Story 2
I eat lunch with my friends.
Sometimes we talk about the Chiefs.
Sometimes we talk about the Royals.
Sometimes we talk about things that confuse me and make me feel bad.
Sometimes when we talk about confusing things, I get angry.
I will remember to tell my teacher during my visit.
After lunch, I need to put my ID card away in my locker and get my notebook.
I need to get to my PE class on time.

Bock, M., Rogers, M. F., & Myles, B. S. (2001). Using Social Stories and Comic Strip Conversations to Interpret Social Situations for an Adolescent with Asperger Syndrome. Intervention in School and Clinic, 36(5), 310-313.
(AS is now ASD per DSM-5.)

The box directly below contains references for the above article.

Personal Reflection Exercise #7
The preceding section contained information about using social stories and comic strip conversations to interpret social situations for an adolescent with Autism Spectrum Disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

Prefrontal Circuits Guiding Social Preference:
Implications in Autism Spectrum Disorder

- Fortier, A. V., Meisner, O. C., Nair, A. R., & Chang, S. W. C. (2022). Prefrontal circuits guiding social preference: Implications in autism spectrum disorder. Neuroscience and biobehavioral reviews, 141, 104803.

Peer-Reviewed Journal Article References:
Alostaz, J., Baker, J. K., Fenning, R. M., Neece, C. L., & Zeedyk, S. (2021). Parental coping as a buffer between child factors and emotion-related parenting in families of children with autism spectrum disorder. Journal of Family Psychology.

Birmingham, E., Johnston, K. H. S., & Iarocci, G. (2017). Spontaneous gaze selection and following during naturalistic social interactions in school-aged children and adolescents with autism spectrum disorder. Canadian Journal of Experimental Psychology/Revue canadienne de psychologie expérimentale, 71(3), 243–257.

Bos, D. J., Silverman, M. R., Ajodan, E. L., Martin, C., Silver, B. M., Brouwer, G. J., Di Martino, A., & Jones, R. M. (2019). Rigidity coincides with reduced cognitive control to affective cues in children with autism. Journal of Abnormal Psychology, 128(5), 431–441.

DeQuinzio, J. A., Ruch, S. A., & Taylor, B. A. (2020). Teaching children with autism to respond to joyful and fearful expressions within social referencing. Behavioral Development, 25(1), 17–29.

Field, T. (2017). Imitation enhances social behavior of children with autism spectrum disorder: A review. Behavioral Development Bulletin, 22(1), 86–93.

What are social stories and comic strip conversations and how are they helpful for an adolescent with Autism Spectrum Disorder? To select and enter your answer go to Test.

Section 15
Table of Contents