Improving interactions of transition-age peers with visual impairment and intellectual disability

Abstract

This collaborative action research study addressed the interaction skills of two young adults with visual impairments and intellectual disability in the context of a board game. The intervention involved the use of an adapted board game, four social stories, and rehearsal of game play skills in the context of individual and group therapy sessions. Instructional strategies included clear within and between activity routines, least to most prompting system, sufficient wait time, and modeling of game play behaviors. Both young men improved their initiation skills, terminated interactions appropriately with fewer prompts, and learned some of the elements of board game play. Self-stimulation and anxiety over changes in their daily lives impacted progress. More research is needed to investigate the potential benefit of social stories for students with visual impairments and additional disabilities.

Keywords

Action research interactions social skills social stories transition age youth

Social skills are a key element in establishing and maintaining friendships (Tipton et al., 2013), in engaging with one’s community (Sacks & Wolffe, 2006), and in employability (Botsford, 2013). As important as social skills are, individuals with disabilities often struggle in this area. Those with visual impairments (low vision or blind), intellectual disabilities, and autism spectrum disorder (ASD) are no exceptions, and when these disabilities occur concomitantly, the challenges with social skills are exacerbated.

Children with visual impairments, with and without additional disabilities, often demonstrate social skills deficiencies that hinder peer interactions (Celeste, 2006; Li, 2009). As they age, their social skills improve, but the discrepancy between their abilities and those of typically developing peers continues to widen (Papadopoulos et al., 2011). Children with visual impairments are more likely to engage in solitary activities rather than interacting with peers (Celeste, 2006; Zebehazy & Smith, 2011). Zebehazy and Smith (2011) asserted that visual impairments pose a disadvantage to establishing and maintaining joint attention and in sustaining interactions. When interactions are attempted, difficulties can occur in initiating, sustaining, or terminating interactions (Celeste, 2006). Papadopoulos and colleagues (2011) found that coping skills, including the ability to appropriately terminate an interaction, were the subdomain of social skills with the lowest performance by individuals with visual impairments.

Interaction challenges are primarily attributed to limited or lack of visual input. Individuals with a visual impairment have difficulty observing – and thus, learning from – the interactions of others (Jindal-Snape, 2005). They also miss the visual-social cues of peers that provide feedback on their own social behaviors (Celeste, 2006; Jindal-Snape, 2005; Papadopoulos et al., 2011). As children mature, their interactions become more complicated (Celeste, 2006), but social skills instruction often takes a backseat to academics (Papadopoulos et al., 2011). When initial instruction has been successful, social skills are resistant to generalization (Jindal-Snape, 2004).

Similarly, most students with intellectual disabilities have weaker social skills than typically developing peers (Elliott et al., 2002), which results in friendships that may not be close and demonstrate less reciprocity (Tipton et al., 2013). Adolescents with intellectual disabilities are more likely to have individual relationships with peers than to be part of a peer group (Tipton et al., 2013); however, they interact with adults much more frequently than with peers (Carter et al., 2005). Although individuals with intellectual disabilities are more dependent on adults to create optimal communication opportunities, McConkey et al. (1999) found that adult caregivers tended to use questions or directives and often communicated in sentences that were difficult for adults with intellectual disabilities to comprehend.

Children with ASD are known to have three core areas of difficulty: social, communication, and limited interests and compulsivity (Heflin & Alaimo, 2007), all of which create difficulty when interacting with peers. For example, it may be challenging for a child who is highly focused on a limited number of interests to share attention over a topic or activity chosen by another.

Individually, visual impairments, intellectual disability, and ASD result in challenges with social skills and peer interactions. In combination, however, the difficulties are amplified. The increasing prevalence of visual impairments with additional disabilities (Alimovic, 2013) warrants consideration of these combined effects. Evenhuis et al. (2009) found that although communication and social skill abilities are largely dependent on the severity of an adult’s intellectual disability, having a concomitant visual impairment exacerbated the weaknesses. Children with these comorbid conditions are characterized as having trouble imitating others, generalizing what they have learned, initiating interactions, and engaging in commonplace activities (Li, 2009). Such students may remain socially isolated until someone can facilitate their interaction with peers. ASD can co-occur with visual impairments, but due to similar characteristics and inadequate diagnostic tools, the two may be hard to distinguish (Li, 2009), resulting in an ASD diagnosis for some while others are described as having autistic characteristics. The factor that amplifies social skills difficulties for individuals with visual impairments and intellectual disabilities is challenging behaviors, which are likely to be exhibited regardless of the ASD-autistic characteristics distinction (Evenhuis et al., 2009; Tipton et al., 2013).

The two student participants in this study exhibited social skills challenges discussed in the literature, including infrequent and very brief interactions with peers, behaviors that interfered with interactions, and struggles with initiating, sustaining, and terminating interactions. This study aimed to support these students with concomitant visual impairment and intellectual disability (and autistic characteristics in one student) to improve their interactions with peers, while reducing dependency on adults, in the context of an adapted board game. In line with recommendations by Plavnick et al. (2015), this intervention utilized a social skills group approach to instruction, paired with individual speech-language therapy sessions, conducted in the participants’ school.

Methods

Action research is a problem-solving form of research featuring one or more cycles of action and reflection (Bruce & Pine, 2010). This study was designed as action research because of its suitability to address complex topics in complex contexts, its amenability to changing an intervention in response to participant responses to intervention, and its focus on improving professional practice (Putman & Rock, 2018). This collaborative action research study involved two cycles, the first in the school setting and the second in the dormitory setting. This study was approved by the first author’s Institutional Review Board. Adult participants and parents of the students provided consent; the students provided assent. The primary research question was as follows: How will direct instruction, in the context of a leisure-based activity, impact the interaction skills of post-secondary learners with visual impairment and intellectual disability? Sub-questions were as follows: How will students’ efforts to initiate interaction with a peer change in response to the intervention? How will students’ turn-taking with a peer change in response to the intervention? How will students terminate interactions during the board game? How will the game play and quality of interactions among peers change over time?

The two young adult students were Matt and Jason. Matt was 20 years old, blind (right prostheses, light perception only in left eye) with intellectual disability (level unnamed). Jason was 21 years old, blind (no light perception; retinopathy of prematurity), with moderate intellectual disability and autistic characteristics. Both students were placed in a residential school for the blind and resided in different dormitories.

Adult participants included two Speech-Language Pathologists (SLPs) who usually served these students in individual therapy sessions. Dormitory staff participation was limited to completion of the pre- and post-surveys.

Intervention

Each student received their weekly individual SLP session; the weekly interaction sessions were additional with both SLPs present. The protocol for each individual session was: SLP reviewed the agenda for that specific session, SLP introduced a social story for the targeted element of interaction, the student practiced that element with the SLP, and the student and SLP reviewed the session.

The interaction sessions involved both student participants and both SLPs in the context of sharing an adapted board game created by the SLPs. Nine interaction sessions occurred in school followed by three sessions in one student’s dormitory to support generalization. Across the interaction sessions, the SLPs took turns being either the facilitator or a game player. The protocol for each interaction session was as follows: students traveled to the room, students greeted each other, the SLP (facilitator) read the social story (previously introduced in individual sessions), students and the second SLP played the adapted board game, and students appropriately concluded the session. The SLPs provided modeling, prompting, and instruction, as needed, for each element of the interaction.

The social stories

Four social stories were developed by the SLPs, introduced one at a time, and reviewed across multiple sessions. The first social story was the Hello Story. This addressed greeting others by saying hello, listening for others, listening posture, responding to others, and the names of the people who would be playing the board game. The second social story was Introduction to Board Games. This story introduced game-related terms (e.g., board, game piece, spinner, talking dice), turn-taking, how to begin and end a board game, and moving across the board. The third social story was Ending an Activity. This story explained how to know when an activity is over, cleanup, and leaving the room. The fourth social story, Board Games-Wrap-Up reviewed how to play board games with elements from the earlier three stories and noted that board games could be played in different environments.

The game

The adapted board game, developed by the SLPs, consisted of 20 spaces. Different textures signified special types of spaces (that appeared every 2–3 spaces) and the start and finish spaces. Special spaces included Name that Sound (e.g., birds chirping, lawnmower, vacuum); Name that Tune (performed by the students’ preferred artists); Name that Category (e.g., breakfast foods); and Name Current Events (e.g., holidays, personal news, world news events). When a student landed on one of these special spaces, he listened to a musical clip or a narrated question. Special spaces also served as a natural reinforcer for engaging in game play.

Data sources

Four data sources informed this study: pre- and post-surveys, observations, SLP checklists, and SLP journals. The purpose of the surveys, completed by dormitory staff, was to learn more about the students’ preferred activities; how they initiated, sustained, and terminated social/leisure activities with peers; the level of adult support they required; and to monitor change from the pre- to post-intervention. Observations were the second data source. Each interaction session was videotaped in its entirety. These videos were analyzed to determine changes in student performance and to identify the instructional strategies applied in the interaction sessions. The videos were also viewed by the SLPs to complete the third data source, a checklist with 33 items that were closely aligned with the sub-questions about interactions. This checklist included eight items on initiation skills (such as responding to the presence of a peer and orienting body and face toward peer), nine items on turn-taking (such as passing object to peer, listening when others speak, and number of board game turn cycles), three items on terminating interactions (such as expressing an appropriate exit greeting), and 13 items on quality of interactions (such as refraining from engaging in echolalia, using peer’s name during interaction, and showing interest or kindness toward peer). The checklists (for each student and each session) were completed by the SLPs after they viewed each interaction session video. The level of prompting required for each of the items on the checklist was rated by the SLPs, ranging from no response to independence. Both SLPs recorded notes from each interaction session in journals, which included comments on student performance and ideas for instruction. Thus, the videos were viewed and coded by three individuals, the researcher–collaborator and the two SLPs.

Data analysis

The pre-surveys were analyzed for ideas about what to include in the interaction sessions, especially content for the spaces in the adapted board game. This ensured that the game was well connected to student preferences, such as listening to music and identifying song titles and artists. The pre- and post-surveys were compared for potential changes in student interactions in the dormitory.

The researcher–collaborator viewed each observation video three or more times, initially organizing notes on each video observation by student and observation date, within a priori categories that related to the study’s research sub-questions, such as initiation and joint attention, taking turns and sustaining interactions, terminating interactions, quality of interactions, and instructional strategies. Within the first analysis document, notes within the category of initiation for one session included the following: “During the Hello story, Jason directed his face toward Matt without a prompt. Later, Jason required a prompt to attend to Matt.” Contextual notes, such as a change in social story or life events that may have impacted student performance were also noted. The researcher–collaborator then coded notes across sessions for each student, identifying key findings for each. For example, she commented that while they listened to each other, they more frequently initiated with adults. In a second analysis document, the researcher–collaborator organized the above notes and key findings by student and across sessions to provide a clear picture of each student’s performance across time.

The SLP checklists, that included items related to initiating, sustaining and terminating interactions as well as items on the quality of interactions, were analyzed by a graduate assistant. Each item was coded for the prompting level that was required to elicit the desired behavior, with prompting levels defined at a high level of specificity. For example, minimal verbal prompting was defined as one or two verbal prompts; whereas maximal verbal prompting was defined as five or more verbal prompts. These prompting levels were assigned numerical values, which were summed within and across sessions. This analysis identified potential changes in level of independence across interaction sessions.

The researcher–collaborator and a graduate assistant independently conducted a line-by-line thematic analysis (e.g., identifying topics; Flick, 2014) of the SLP journals to identify themes, and key words or phrases that were examples of the themes. The analysis included a priori categories that corresponded with research questions about initiating, sustaining, and terminating interactions, and instructional strategies, as well as emerging themes that included interfering behaviors and comments on the effectiveness of instructional strategies. When the two coders identified very similar theme names, they were merged and renamed as necessary, with all other themes remaining intact.

Results

Findings are presented by the focus of each research sub-question: initiating, sustaining interactions, terminating interactions, quality of interactions and game play, and instructional strategies. The observation videos, SLP checklists, and SLP journals provided data on how the students initiated, sustained, and terminated interactions, as well as about the quality of their interactions. Instructional strategies were identified from analysis of the observation videos.

Initiating interactions

Initiation included the students’ use of communication to gain attention and their responses to bids for attention from others. Across the interaction sessions, both students were attentive to their SLPs and were more likely to initiate communication with them than with their peer. Evidence of their attention to adults included correct responses to questions posed by the SLPs and body movements aligned with SLP requests and suggestions. Generally, they attended to the facilitating SLP as she read the social story. Across sessions they were more likely to display unprompted responses to SLP greetings than peer greetings. In Session 3, both students greeted each other saying, “hi, Jason/Matt.” In that session, Matt initiated the comment, “here you go, Jason” as he passed the talking dice. In Session 4, when Matt was uncharacteristically quiet, Jason remarked, “he doesn’t want to talk,” demonstrating attention to his peer’s mood. One of the SLP journals noted, “Matt showed emerging use of gesture to gain the attention of his peer by raising his hand and waving it toward his peer to get his attention” paired with verbalizing, “excuse me, Jason, I want a turn” while spontaneously orienting his face toward his peer.

Overall, noise levels, body postures, and their own distractions (e.g., singing, sadness, changes in routines) affected attention to their peer. Initially, the change of setting to the dormitory reduced joint attention and initiation, probably due to the noise level on that day and the anxiety Matt experienced over this change. Also, in Session 6, Matt was engaging in echolalia and was unresponsive to Jason’s initiations. Jason then engaged in self-stimulatory behaviors such as singing and delayed echolalia. Poor posture and lack of physical orientation to peer remained an issue across the sessions for both students.

Both students had fluctuating performance over time. Matt showed some improvement in the frequency of unprompted initiations. When Matt required a verbal prompt, he was able to respond to a suggestion or cue, such as “What do we do when . . .” rather than a directive. Across sessions, his most frequent initiation behavior was to identify his peer, followed by using words to gain attention of his peer. The post-survey indicated that Matt began greeting peers in the dormitory by saying “hi” but continued to need prompting to elaborate, such as asking peers about their day. Jason continued to be more dependent on verbal prompts. His strongest initiation and joint attention skills were to identify his peer and respond to the presence of his peer. No change was reported for Jason’s generalization of initiation behaviors in the dormitory.

Sustaining interactions

Data on sustaining interactions largely focused on turn-taking. It is important to note that the social story about taking turns was not introduced until Session 5. Matt consistently understood whose turn was next, between the three players. Matt was also consistent in using his peer’s name, a good turn-taking strategy for individuals with visual impairments. Jason was not clear about whose turn it was and required some prompting from the SLP or peer. Both students learned social scripts and could insert the appropriate message within a specific routine. Both improved in learning the appropriate messages, but Jason required a higher level of prompting. Across sessions, both students modified their turn-taking messages to their peer. Matt tended to say, “Here you go, Jason” and Jason said, “Here, Matt” as he passed the dice. Although Matt preferred to take the first turn, in Session 9, he offered this opportunity to Jason. Session 9 was a strong session for both students, with one SLP remarking (in her journal) that they were attending to exchanges, such as reaching out for dice or commenting.

Often the students required physical assistance from the facilitating SLP to take their turns, due to limited experiences in playing board games. This included assistance to know where their game piece was and how to move it around the board. There were also examples of both students prompting each other on turn-taking. Jason learned to pass the dice and tap on the table for Matt who picked up on his auditory cue. In one session, Jason provided a less direct cue in saying, “so you’re finished with the dice” at which time Matt inferred that it was time to pass the dice. The most frequently demonstrated independent game play behaviors were accepting objects from peer and passing objects to peer.

Both students engaged in interfering behaviors that affected turn-taking during game play. Matt had a strong tendency to have his head up on his turn and his head down during Jason’s turn. Sometimes they verbalized the answer to the question on a special space when it was not their turn. One SLP remarked about Session 8 in her journal, “Both students had difficulty inhibiting responses when it was not their turn and when a person landed on a specific game category.” Self-stimulatory behaviors, such as echolalia/delayed echolalia, fingers in the eyes, and brief bouts of singing further interfered with turn-taking. The first session in Jason’s dormitory was difficult for Matt because he was not sure what it meant to be in his peer’s dormitory. He engaged in singing during his peer’s turn. Off-topic talk greatly affected the variation in turn-taking cycles across the sessions. Jason’s off-topic talk occurred on his own turn, whereas Matt’s off-topic talk occurred during Jason’s turn. Some difficulties in interaction seemed to be around a lack of understanding about game procedures (see Quality of Game Play).

Overall, both students exhibited gradual improvement in turn-taking around objects, but not as much in verbal interactions. Matt’s turn-taking and use of language around turn-taking improved over time, but was highly variable across sessions. Although he did not demonstrate much improvement across sessions, Jason was quiet and very good at waiting for his turn. His most frequently demonstrated turn-taking behaviors were accepting objects from peer, passing object to peer, and listening to others when they talked. No difference in turn-taking was noted for Matt or Jason across the pre- and post-surveys on dormitory behavior.

Terminating interactions

Matt did not demonstrate terminating behaviors in the first session and Jason exhibited only exit greeting in that session. The students’ exit interactions were quite brief, consisting of saying good-bye and in some sessions thanking each other. At times, the SLPs supported the students to expand their utterances. For example, in Session 2, they were told that it was the end of the game. Matt said, “Thank you Jason.” The SLPs then prompted him to expand his message and he then said, “Thanks. Good-bye. See you next time.” Matt was generally first at giving the exit phrase in response to a cue, but in Session 9, Jason was the first in responding to the cue. In the final session, Matt sought to end the game early. In Session 5 and in the final session, when told that it was the end of the game, Matt remarked, “Bye, Jason” and Jason independently responded with “Bye, Matt.”

Jason’s quiet and passive nature made him more likely to respond to the terminating behaviors of the SLP or his peer, rather than suggesting termination of the game. This is also tied to the students’ social expectation that adults determine when sessions begin and end. Matt’s off-topic talk and body positioning was sometimes an indication that he was not interested in continued game play, even though he did not verbalize a desire to terminate the game.

Across sessions, Matt developed terminating skills, such as exit greetings, but his performance varied across the intervention sessions. Jason verbalized exit greetings early in the study, but did not gain additional terminating skills. Both students struggled with terminating an interaction, but they improved their ability to respond to subtle verbal cues. Indirect cues were needed as time went on as opposed to directives or modeling the exact expected message. Across the pre- and post-survey, no difference in generalization of terminating interactions in the dormitory was noted for either Matt or Jason.

Quality of interactions and game play

Both student participants were more likely to interact with adults than with each other. Both responded to direct instruction within a session, but the benefit of the instruction did not consistently follow through to future sessions. For example, in Session 2, instruction on good listening resulted in some improvement in heads being up and in looking toward partners during that session, but reminders were necessary in subsequent sessions. In addition, both students demonstrated difficulty inhibiting their responses when excited over a special space their peer landed on. The students also showed marked improvement in game play beginning in Session 8, requiring less prompting. This improvement continued in Session 9 when they each took four turns and reciprocation was good. During Session 11, both students were using assistive technology to support the reduction of anxiety and behavior state regulation. By Session 13, Jason was performing the game, but needed greater support for verbal aspects of the game and he required more wait time that session. In the same session, Matt displayed an emerging awareness about how to comment to friends, although he required verbal prompts and modeling. During that session, Matt put his piece on the correct starting space and Jason needed minimal support to do the same. They both improved in counting game spaces but did not always remember to use both hands (with one used as a place holder). In Session 14, both students did better with non-verbal turn-taking behaviors, such as reaching out for game parts.

Off-topic behavior and the emotional impact of changes in routine were most likely to interfere with the quality of their interactions. Matt’s off-topic behaviors included laughing, singing, angry comments, tapping, hitting objects, and mild self-injurious behaviors, which he pointed out verbally. For example, during one session, he repeatedly poked his wrist while remarking, “I’m poking myself. I hurt myself.” Jason was much quieter, but also engaged in off-topic talk and occasionally, singing. If either student sang during adult talk, the singing would stop when the adult stopped talking. Matt’s repetitive hitting of the talking dice improved across sessions, but worsened in the final session. Changes in their daily routines and in settings also had marked impact on both students. Matt was quite upset about an anticipated assembly in one session. In another session, Jason was very sad because he had just moved into a new residence. In a later session, Matt’s performance dropped dramatically when instruction occurred in Jason’s dormitory (as part of generalization). When expectations were violated, both students struggled to interact.

Over time, the quality of interaction improved for both students. Matt’s performance fluctuated across sessions but nonetheless demonstrated a trend of improvement. His best skills related to quality of interaction were for expressing appropriate exit phrases, using his peer’s name during interaction, and being respectful of the adults who supported the interaction. Jason’s two most often expressed skills were being respectful of the adult staff who supported the interactions and using his peer’s name during the interactions.

Instructional strategies

Throughout intervention sessions, the SLPs applied the following instructional strategies: (1) teaching within-activity and transition routines (which included entry and exit greetings); (2) establishing environmental arrangements specific to students’ needs for physical space; (3) applying assistive technology (e.g., fidget and weight pad) to address sensory needs and reduce interfering behaviors; (4) previewing and reviewing of expectations; (5) applying the least-to-most prompting system; (6) modeling of game play, communication, and social skills; (7) offering sufficient wait time; (8) providing ample opportunities for discussion, especially about upsetting events that precipitated interfering behaviors; (9) ignoring mild behaviors (e.g., low-level noisemaking or overuse of talking dice); and (10) providing reinforcement, usually verbal. In addition, the SLPs applied strategies responsive to the students’ visual impairments, including using names rather than eye contact to draw attention, using consistent vocabulary and messages during game play, providing information about social skills that are generally observed through vision, and explaining adaptive behaviors to facilitate game play (such as tapping dice lightly on the table to indicate location for partner).

Discussion

The adolescents in this study required instruction and ongoing support with all aspects of interactions: joint attention and initiation, turn-taking, and terminating interactions. Matt made greater improvements in unprompted initiations than in sustaining or terminating interactions, perhaps because the first social story was about greetings, so he had more opportunities to rehearse those skills. Both students used their peer’s names, a good joint attention strategy, especially for peers with visual impairments. Matt was clearer than Jason about whose turn it was, but both students learned turn-taking messages. After instruction and modeling, both were able to perform some of the sustaining aspects of game play, such as passing objects to peers and counting spaces. Both students expressed appropriate exit greetings, although often they needed prompting. Self-stimulatory behaviors and anxiety-related behaviors were common and caused fluctuation in student performance. Indirect cues rather than directives were often effective in supporting positive behavior. Careful planning of the environment, the selection of materials to support sensory needs, within and between session routines, preview, review, repetition, and least intrusive prompting supported game play and appropriate interaction skills.

Visual impairment greatly reduces access to social information, including social cues, social modeling, and the reactions of others (Ivy et al., 2016; Runjic et al., 2015). Individuals with intellectual disability may experience histories of limited peer interactions (Carter et al., 2005), thus reducing their opportunities to practice social skills, and increasing their reliance on adults. The students in this study had difficulties establishing joint attention and taking turns with a familiar peer, also reported by Zebehazy and Smith (2011) as difficulties attributed to vision loss. Like Celeste (2006), we found that the student participants were more likely to exhibit unprompted responses to adults than to peers, and that they were prompt dependent on adults. The participants in this study had severe visual impairments that greatly reduced access to social cues, in keeping with findings by Celeste (2006), Jindal-Snape (2005), and Papadopoulos et al. (2011). Their lack of familiarity with board games created the need for additional support from adults.

This study confirms the findings of others relevant to the impact of visual impairment combined with intellectual disability on social skills, specifically in the context of sharing a board game with a peer. It also affirms the role of interfering behaviors in fluctuating student performance, while suggesting instructional strategies to support improved behavior and social skills. Social skills training groups, social narratives (in this case, social stories), and behavioral strategies (such as prompting and reinforcement) are evidence-based practices for children with autism (Odom et al., 2010) that were effective with these students. This study suggests that social stories that are shared repeatedly may be helpful to preparing students with visual impairments combined with intellectual disability and/or autism for social situations.

Implications for research

There is a need for additional studies on the applicability of social stories to the instruction of social skills in children and young adults with visual impairments and intellectual disability or autism. There is also a need for more research on leisure-recreation and specifically board games.

Implications for practice

This study suggests several implications for practice. Careful environmental engineering, including seating and devices to support sensory needs can support calmness, which is conducive to positive interactions. Well-established routines, direct instruction, repetition, rehearsal, and a plan for generalization may support learners with visual impairment and additional disabilities to gain social skills. Perhaps most important, instruction of social skills should begin in the preschool years with children being provided with ample opportunities to interact with peers.

Limitations

One important limitation of this study is that only two students participated. Thus, the findings cannot be generalized to other students with visual impairment and additional disabilities. The length of the study is another potential limitation. Perhaps a longer intervention period would have produced greater improvement in interactions.

Conclusion

This study demonstrated that when provided with direct instruction based on behavioral principles such as prompting, modeling, and reinforcement, two young adults with visual impairment and additional disabilities increased their initiation with a peer and terminated a leisure activity with reduced prompting. Both students learned elements of game play and benefited from social stories to learn language appropriate to playing a board game with a peer. Interfering behaviors limited their progress and caused fluctuating performance across interaction sessions. More research is needed to determine the effectiveness of social stories for individuals with visual impairments and additional disabilities.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Michael and Susan Argyelan Education Research Fund and the Perkins School for the Blind Research Fund.

ORCID iD

Susan Bruce

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