Efficacy-focused randomized controlled trial of social skills training in children with autism spectrum disorder using Social Stories via electronic book

Introduction

Autism spectrum disorder (ASD) is a common neurodevelopmental disorder with increasing prevalence worldwide (1). Epidemiological data from the USA have identified the prevalence of ASD as approximately 1 in 54 among children aged 8 years, with males being disproportionately affected at 4.3 times the rate of females (2). Moreover, data from 2016 reveal a continual rise in the prevalence of ASD in Asia, with an estimated incidence of 0.36%. In Thailand, the Department of Mental Health (3), reported the prevalence of ASD to be about 1 in 160 or 6.25 per 1,000 population, and a study by King Chulalongkorn Memorial Hospital (4), in 2016 found a prevalence of 1 in 81 among pediatric outpatients, highlighting the growing burden of ASD and the urgent need to develop effective intervention strategies. ASD is typically diagnosed before the age of 3 years, with challenges in communication and social interaction evident from an early stage (5). Key features of ASD include difficulty in eye contact, facial expressions, body language, and tone of voice, as well as difficulty in reading and responding appropriately to the thoughts and feelings of others (5,6). These impairments can significantly impact social interaction, group integration, and the formation of friendships with peers. While these challenges may not be directly related to intellectual ability, they can have a profound negative effect on the ability to form and maintain meaningful social relationships, adapt to school, and achieve long-term success (7) in life.

Social competencies represent a fundamental foundation for the holistic development in children, particularly during preschool age when brain growth accelerates (8) and exhibits high plasticity. Early social-emotional functioning is linked to later wellness and public health outcomes (9).

Acquiring and applying social skills from an early age helps children build essential foundations for effective communication with peers, understanding societal rules and norms, and exploring diverse environments, which positively affects their overall development, including linguistic, cognitive, emotional, and psychological well-being.

In contrast, lack of social skills in early childhood may result in social rejection or exclusion, feelings of loneliness and isolation, learning difficulties, anxiety and depression, and difficulties in establishing personal relationships later in life (10). Hence, a collaborative effort has emerged to develop effective interventions to enhance social skills in children diagnosed with ASD from their earliest developmental stages.

Social Stories (11,12) has been used widely and extensively for enhancing social skills in children with ASD (13). This research approach narrates real-life scenarios while providing guidance on various responses through descriptive language, perspective-taking, and behavioral instruction. Prior empirical studies (6) substantiate the efficacy of Social Stories in promoting appropriate social behavior (7), enhancing communication skills, and interactive play skills (14,15), and reducing maladaptive behaviors (15). Despite supporting evidence, significant research gaps such as the practical implementation of Social Stories in real-world settings still remain. Key concerns include accessibility, usability, and acceptance by both parents (16) and children, which may ultimately affect the effectiveness of their practice.

Furthermore, there is a need to enhance the engagement of Social Stories by customizing them to the specific needs of each child and integrating with more advanced technologies (17), such as digital systems, interactive learning media, and other participatory techniques. Combining Social Stories with other methods, such as video modeling (18), multimedia (19), or music therapy (20), may increase learning motivation and improve children’s information processing.

However, research on integrating Social Stories with other approaches is still limited, which needs to be studied further to confirm their effectiveness, feasibility, and factors influencing real-world implementation. Therefore, this study aims to explore the efficacy of implementing Social Stories through electronic books (e-books), a highly accessible and convenient medium in contemporary society, to cultivate fundamental social skills, specifically eye contact and greeting, among preschool-aged children with ASD within the Thai context. The primary aim is to address the knowledge gap of using Social Stories in real-life scenarios and to develop strategies that reduce disparities in service access for families facing various challenges. The results of this research are expected to make significant contributions to the development of more holistic interventions and methodologies for children with special needs, ultimately improving the quality of life at individual, familial, and societal levels.

Objectives

The objective of the present research is to investigate the efficacy of employing social narratives via e-books in promoting fundamental social competencies, particularly eye contact and greeting, in preschool children with ASD, in comparison to a control group that receives standard social skills training via online meetings devoid of Social Stories. This study aims to assess the effectiveness of applying this methodology in real-world settings and to address the existing knowledge gap regarding the improvement of social skills in children with ASD within the context of Thailand. We present this article in accordance with the CONSORT reporting checklist (available at https://pm.amegroups.com/article/view/10.21037/pm-25-10/rc).

Methods

This study was registered with the Thai Clinical Trials Registry (TCTR20260511009) in accordance with recognized clinical trial registration standards and reporting requirements. The intervention used Social Stories based on Carol Gray’s principles, including descriptive, perspective, directive, and affirmative sentences, emphasizing factual information, others’ viewpoints, and appropriate behavior. Stories followed the recommended sentence ratio, using simple, concrete language suited for Thai preschoolers with ASD. They were co-developed with pediatricians, psychologists, and caregivers to ensure cultural and linguistic relevance. Twelve stories were created, focusing on core social skills like greetings, turn-taking, and emotional expression, and delivered over six weeks (two per week). A detailed description of the story structure, content, and delivery is provided in the “Methods” section, with examples in the supplementary materials.

Sample size

The study is a randomized controlled trial (RCT) conducted between February 1, 2023 and March 31, 2024 involving 52 preschool-aged children between 5 and 7 years old, who have been diagnosed with ASD in accordance with the DSM-5 (13). The participants were selected through purposive sampling from the child development center at Queen Sirikit National Institute of Child Health (QSNICH). The inclusion criteria mandated that participants must have an intelligence or developmental score exceeding 70, as evaluated by the Gesell Drawing Test or the Test of Nonverbal Intelligence, fourth edition (TONI-IV) (21), alongside the capacity to engage in basic communication (16). The >70 cutoff was chosen to ensure participants had sufficient cognitive and language skills for the intervention, reduce variability, and align with common practices in ASD research. This communicative ability was evaluated through a combination of clinical judgment during developmental assessments by developmental-behavioral pediatricians; standardized tools such as the Thai Developmental Screening Test (TDST) and the Preschool Language Scale (PLS-5), which assessed receptive and expressive language skills; and caregiver reports and observations during intake, focusing on behaviors such as following simple instructions, expressing basic needs, and demonstrating joint attention. Children who could respond to verbal prompts, make eye contact, and communicate using words, gestures, or augmentative methods were considered to meet the threshold for basic communication.

Parents were required to demonstrate readiness to utilize technological methods and collaborate with the research team by receiving standardized orientation and training prior to beginning the 6-week program to ensure consistent and effective delivery of the intervention. This training included a 60-minute live virtual session conducted by a developmental-behavioral pediatrician and a child psychologist, covering the principles and purpose of Social Stories™, interactive strategies for reading the e-book content with their child, and techniques to promote engagement, such as encouraging responses and using gestures and facial expressions. To reinforce key concepts, caregivers were also provided with a written manual and a video demonstration for at-home reference. Weekly 15–20-minute check-in calls were conducted to address questions, troubleshoot challenges, and support adherence to the intervention protocol. The training focused on both technical aspects, such as navigating the digital platform, and behavioral strategies aligned with social communication goals, ultimately promoting high fidelity and caregiver confidence in implementing the program.

Likewise, it was imperative for the young participants to reveal typical auditory and visual capabilities, in addition to recognizable impairments in social interactions, before the research commenced. Exclusion criteria encompassed parental proficiency in languages other than Thai and the presence of epilepsy, cerebral palsy, genetic disorders, or sensory disabilities in the children. The sample size was determined using G*Power 3.1.9.2 software. Based on previous studies of social skills interventions in ASD, we anticipated a medium effect size (Cohen’s d=0.6) for the primary outcome. A randomized trial by Sansosti et al. [2004] (22) reported medium to large effect sizes (d=0.5–0.7) for improvements in social responsiveness following Social Stories-based interventions.

Randomization and implementation

The subjects were randomly distributed into either the experimental or control group, using R statistical software (Version 4.0.3) by an independent statistician. A stratified block randomization was used with block sizes of 4 and 6 to ensure balanced allocation while maintaining unpredictability. Stratification was performed based on parental education level (high school or less vs. post-secondary education) to control for potential confounding effects of family background on intervention delivery and outcomes.

The allocation sequence was concealed from researchers and participants in a sealed envelope. After confirming eligibility and obtaining informed consent from the participants, the envelope was opened to reveal the group categorization. However, blinding of participants and caregivers was not fully possible due to the nature of the intervention. The outcome assessments were conducted by a trained developmental behavioral pediatrician who was blinded to group allocation and independent from intervention delivery. They were instructed not to discuss group assignments with participants and caregivers, who were also advised not to disclose their group assignments. To evaluate the effectiveness of blinding, assessors were asked to guess participant group assignments after each assessment.

The participants were divided into 2 groups: the experiment group of 22 persons, and the control group of 22 persons (Figure 1). The experimental group received training with e-book Social Stories, with parents reading two stories per week for 6 weeks. The intervention group was instructed to record brief video segments (approximately 5–10 minutes in length) of each e-book-based Social Stories session conducted with their child. These videos were submitted securely to the research team via a password-protected cloud storage platform. The purpose of these videos was not to assess outcomes, but to ensure fidelity of intervention delivery—that is, to confirm that caregivers were implementing the Social Stories as instructed and maintaining consistency with the prescribed protocol. The research team used a standardized fidelity checklist adapted from existing Social Stories implementation guidelines to qualitatively assess whether key components (e.g., caregiver narration, child engagement, reading frequency, and use of visual aids) were present. These fidelity checks were not used for statistical analysis but served as a monitoring tool to ensure adherence to the intervention protocol.

Figure 1 CONSORT flow diagram of participant enrollment, randomization, allocation, follow-up, and analysis.

The control group received standardized social skills training developed by a clinical psychology team, focusing on core domains such as turn-taking, greetings, emotional expression, and sharing. This training, which was based on general behavioral principles and incorporated role-playing, verbal reinforcement, and guided discussion, did not include Social Stories or any narrative-based instruction. Sessions were delivered online via video conferencing once per week for six weeks, each lasting approximately 30–40 minutes, mirroring the total time commitment expected from caregivers in the intervention group. These sessions were led by licensed developmental psychologists, with caregivers encouraged to observe but not actively deliver the content—unlike the intervention group, where caregivers facilitated learning through direct engagement with the e-books. Both groups were assessed for social skills using the Social Skills Rating Form adapted from the Autism Treatment Evaluation Checklist (Thai-ATEC) (22), administered by parents’ baseline, after 2 weeks, and after 6 weeks of intervention.

This assessment covers four domains of social skills: the adapted Social Skills Rating Form, which includes 15 items originally grouped into five conceptual domains (Responding to Others, Initiating Interaction, Social Expression, Social Play Skills, and Social Emotional Skills). However, for analysis, the Initiating Interaction and Social Expression items were combined into a single “Interpersonal Skills” domain based on pilot testing and expert consensus, indicating strong conceptual overlap and improved internal consistency. Thus, the final analyzed domains were: Responding to Others, Interpersonal Skills, Social Play Skills, and Social Emotional Skills—understanding and taking the perspective of others, initiating interactions, responding to interactions, and maintaining interactions. Each behavioral item is scored from 1 (not very good) to 4 (very good), with an internal consistency (Cronbach’s alpha) of 0.92 and good content validity. During follow-up, one participant from the control group relocated, resulting in a loss to follow-up. With α=0.05, power =0.80, and accounting for a potential 20% dropout rate, the required sample size was calculated to be 43 participants (22 in the intervention group and 21 in the control group) to detect significant between-group differences.

Research tools

The e-book of Social Stories was developed as a digital tool to support social skill development in children with autism through structured storytelling that integrates narrative and visual elements. This educational resource draws on Gray’s Social Stories model (18), systematically introducing key social interactions, such as eye contact, greetings, and cooperative play, in a way that is engaging and accessible for young children. Utilizing six structured sentence types: Descriptive, Perspective, Directive, Control, Affirmative, and Cooperative, the e-book Social Stories methodically guides children through social scenarios, facilitating the comprehension and application of social cues and responses in real-life contexts. Development of the e-book Social Stories involved an initial content validation by a panel of interdisciplinary experts, including developmental behavioral pediatricians, occupational therapists. This panel reviewed two sample Social Stories focusing on eye contact and greetings to evaluate their accuracy and alignment with educational objectives. The Index of Item Objective Congruence (IOC) was used as the scoring instrument, with values ranging from +1 for content that accurately aligned with objectives to −1 for misalignment. Initial evaluations highlighted areas for revision, leading to refinements in content that resulted in a final mean IOC score of 1.0 after two rounds, indicating high content validity. This validation process underscored the tool’s potential as an effective educational resource for children with autism. Following content validation, practical testing of the e-book Social Stories was conducted with three pairs of parents and their children with autism, aged 5 to 7 years. These participants, not part of the initial sample, engaged with the e-book Social Stories and assessments were conducted immediately and two weeks post-intervention to gauge improvements. Post-intervention analysis using paired t-tests indicated significant score improvements, signaling a reduction in difficulties and enhanced social skills.

Social Skills Training Questionnaire was developed to measure outcomes, adapted from the Thai-ATEC (Autism Treatment Evaluation Checklist) (21), from 18 items of Thai-ATEC to 15 items, with validation approval from Khon Kaen University. The Social Skills Training questionnaire was evaluated by experts in developmental behavioral pediatrics, with 15 items rated on a 4-point Likert scale (1= not very problematic, 2= mildly problematic, 3= moderately problematic, 4= very problematic), with a total score range of 15 to 60. Higher scores indicate greater severity of social skill difficulties; therefore, reductions in scores represent improvements.

The items are grouped into five domains: Responding to Others (3 items), Initiating Interaction (3 items), Social Emotional (3 items), Social Play Skills (3 items) and Social Emotional Skills (3 items), achieving a mean IOC of 0.93. The questionnaire’s reliability was verified through test-retest assessments with three parent participants, achieving a reliability coefficient of 0.81, confirming its consistency as a research tool. The findings further support the use of this tool in educational and clinical contexts, offering a reliable method to improve key social skills through structured storytelling.

However, for analysis, the Initiating Interaction and Social Expression items were combined into a single “Interpersonal Skills” domain based on pilot testing and expert consensus indicating strong conceptual overlap and improved internal consistency. Thus, the final analyzed domains were: Responding to Others, Interpersonal Skills, Social Play Skills, and Social Emotional Skills.

Statistical analysis

Between-group comparisons of baseline characteristics used Chi-squared, Fisher’s exact, and independent t-tests. For the primary longitudinal outcome analysis, we applied generalized estimating equations (GEE) to assess group-by-time interaction effects while controlling for baseline scores, child age, gender, developmental quotient (DQ), and parental education.

The following covariates were included in the final GEE model: baseline total score of the outcome measure, child age, child gender, baseline DQ and parental education level. These covariates were selected based on clinical relevance and previous literature indicating their potential influence on social skill development in children with ASD.

Primary analyses followed the modified ITT using multiple imputation. Between-group differences in social skills outcomes were analyzed using mixed-effects models to account for repeated measures and missing data. The models included fixed effects for treatment group, time, and group-by-time interaction, with random effects for participants. Stratification variables were included as covariates. Effect sizes were calculated using Cohen’s d with 95% confidence intervals (CIs).

Additional analyses examined potential moderating effects of baseline characteristics, including age, gender, and initial social skill levels. We also conducted per-protocol analyses, including only participants who completed at least 80% of intended intervention sessions. All analyses were performed using SPSS version 26.0, with statistical significance set at P<0.05 (two-tailed).

Data analysis was performed employing SPSS software to derive descriptive statistics pertaining to baseline sample characteristics, encompassing frequency, percentage, mean, and standard deviation. Utilizing Student’s t-test, Welch’s t-test, and the Wilcoxon-Mann-Whitney test, we performed inferential statistical evaluations to examine variances between groups and within groups for quantitative variables over several time intervals. In the case of categorical variables, the Chi-squared test was utilized, whereas longitudinal variations were examined through the application of linear mixed models.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by institutional ethics board of Queen Sirikit National Institute of Child Health, Thailand, on July 10, 2023 (No. IRB00007346), and informed consent was taken from all individual participants’ parents. It was necessary for parents to deliver written informed consent before engaging in the study, and they were told that their participation was optional and would not influence the child’s medical treatment at all.

Results

This study was conducted from 1 February 2023 to 31 March 2024, including the follow-up period. The analysis of basic information of the participants, consisting of general demographic, age at diagnosis of autism, frequency of occupational therapy training, birth history, family information, parenting style, and level of intelligence, showed no statistically significant difference, as shown in Table 1.

In order to ensure transparency and reproducibility, “temperament” was measured using the Thai Behavioral Style Questionnaire (BSQ), which classifies children into types based on caregiver responses to 100 items assessing behavioral traits. While parenting style was assessed using a 15-item parent-report tool adapted from Baumrind’s typology, identifying authoritative, authoritarian, and permissive styles. Both tools are validated for use in Thai pediatric settings and were administered at baseline as part of the developmental intake, as shown in Table 1.

When comparing changes between groups in terms of social skills scores, after 2 weeks of intervention, there were significant differences between the two populations. In the intervention group, it was found that scores decreased with statistical significance, both in the total score and in the subtopics on interpersonal skills and peer interaction skills, and also after 6 weeks of intervention. When comparing the intervention group and the control group, it was found that there were significant differences in data between the two populations. In the intervention group, it was found that scores decreased with statistical significance. Both in the total score and in the 2 sub-items as well: interpersonal skills mean and peer interaction skills mean, as shown in Table 2.

When comparing the change in scores in the Intervention group and the control group, comparing the baseline period with 2 weeks and comparing 2 weeks with 6 weeks after receiving the intervention, it was found that scores decreased. Statistically significant in both population groups, both in the total score and scores in the following subtopics: interpersonal skills and peer interaction skills. As for changes from baseline between groups, it was found to be different. Statistically significant both in the total score and scores in the following subtopics: interpersonal skills and peer interaction skills, as shown in Table 2. It is important to note that the scoring system reflects problem severity; thus, reductions in total and domain scores indicate improvements in social skills.

The GEE analysis showed a significant group-by-time interaction for the total social skills score [standard error (SE) =1.22, β=–8.12, 95% CI: –10.52 to –5.72, P<0.001], indicating greater improvement in the intervention group compared to controls. Similarly, significant interactions were found for “Responding to Others” (β=–4.88, SE =0.84, 95% CI: –6.53 to –3.23, P<0.001) and “Interpersonal Skills” (SE =0.77, β=–3.45, 95% CI: –4.96 to –1.94, P<0.001), which demonstrates that the intervention using Social Stories positively influenced specific social skills over time, particularly total scores from parents, interpersonal skills, and peer interaction skills, highlighting its effectiveness in fostering social development compared to the control group.

In total scores of parents, the intervention group showed a significant reduction over time relative to the control group, reflecting improved outcomes. A significant interaction effect further supports the unique impact of the intervention. Significant improvements were also observed in Interpersonal Skills and Peer Interaction Skills, with the intervention group outperforming the control group. These findings were reinforced by significant interaction effects, indicating the intervention’s specific contributions to these areas. However, Table 3 demonstrates that the changes in Social Play Skills and Social Emotional Skills were not associated with significant interaction effects, suggesting the intervention did not distinctly impact these domains. Overall, the intervention proved effective in enhancing critical social skills.

Caregiver satisfaction was assessed through a structured post-intervention survey that included Likert-scale ratings and open-ended questions addressing usability, content clarity, child engagement, and perceived benefits of the e-book format. The results showed that 90.9% of caregivers (20 out of 22) reported being either “satisfied” or “very satisfied” with the e-book format. Qualitative feedback revealed common themes such as appreciation for the story-based format, the ease of using the e-book at home, and the ability to revisit stories multiple times. Additionally, caregivers observed that their children were more attentive and engaged with the e-book stories compared to conventional paper-based interventions.

Discussion

This study provides initial evidence supporting the effectiveness of interactive e-book Social Stories, delivered via tablet by caregivers in the home setting, for improving social communication skills in Thai preschool children with ASD. Children receiving the 6-week Social Stories intervention showed significantly greater gains in eye contact, greetings, peer interactions, and overall social skills compared to the control group. The findings align with a growing body of research demonstrating the benefits of Social Stories for enhancing social abilities (11-15,19,23) in children with ASD. The personalized, concrete storytelling format, bolstered by engaging visuals, may help children with ASD better understand and remember social expectations, leading to increased prosocial (6,24) behaviors. For preschool-aged children, the familiarity and security of the home environment, along with the involvement of trusted caregivers, may foster learning and skills practice (25). The interactive digital delivery also taps into the strong visual processing skills (17,26) and media interests of many children with ASD, potentially boosting engagement and adherence.

Strengths of this study include the randomized controlled design, use of a culturally-adapted and validated outcome measure, as well as the evaluation of an innovative, caregiver-mediated digital intervention integrated into natural family routines. The e-book modality offers a flexible and scalable approach that may help reduce disparities in access to ASD services in resource-limited regions (22,27). However, the modest sample size, brief follow-up period, and reliance on caregiver-reported outcomes are limitations. Larger, longer-term, multi-informant trials with direct assessments of child behaviors and functioning are needed to replicate and extend (28) the findings. Generalizability to other settings and cultures also remains to be established. Additionally, while caregiver involvement is a key advantage, intervention effectiveness may depend on the quality and consistency of Social Stories delivery across families (23,24). Providing clear guidance, training, and ongoing support to caregivers, as well as monitoring treatment fidelity, will be important in future studies and community implementation (29,30) efforts. Integrating Social Stories with other naturalistic developmental/behavioral interventions, such as Pivotal Response Treatment or Early Start Denver Model, is a logical next step to enhance outcomes (31). Comparing the effects of therapist-delivered vs. caregiver-delivered, and digital vs. non-digital Social Stories could elucidate optimal intervention (32,33) strategies. Exploring mechanisms of change, moderators of treatment response, and tailoring the content and format of Social Stories to individual child characteristics are also key research priorities (34-36).

This study is a randomized controlled design, which provides a rigorous test of the intervention’s efficacy by minimizing potential confounding factors (37). The use of random assignment to intervention and control groups helps to ensure that any observed effects are due to the Social Stories intervention rather than other variables. This study distinguishes itself from prior investigations (38,39) into Social Stories by employing a robust methodology. Unlike many earlier studies, which have often relied on less rigorous designs such as single-case analyses or uncontrolled pre-post comparisons, our approach provides a more reliable and generalizable understanding of the intervention’s efficacy. This methodological strength underscores the contribution of our findings to the existing literature. Another notable feature is the development and evaluation of a culturally-tailored, digitally-delivered Social Stories intervention that can be easily integrated into families’ daily routines. The e-book format provides an engaging, interactive, and visually supported platform that aligns well with the learning needs and preferences of many children with ASD, suggesting that structured, narrative-based digital tools can effectively enhance social competencies in children with autism when used consistently.

The involvement of caregivers as the primary interventionists not only enhances the ecological validity and sustainability of the approach but also empowers parents to take an active role in supporting their child’s social-emotional development (40). However, bias may occur due to caregivers’ expectations to perceive improvement, several safeguards were implemented: (I) blinded assessors conducted baseline and follow-up interviews to supplement caregiver reports; (II) video recordings were used to monitor intervention fidelity, offering an indirect cross-check on caregiver adherence and child engagement; and (III) the primary outcome measure focused on observable, behaviorally anchored items (e.g., eye contact, greeting behavior), reducing subjective interpretation. GEE analysis, a method that is suitable for repeated measures in small to moderate samples, to improve accuracy of within-subject correlations over time. Significant findings reflected both between-group differences and within-group improvements in social skills. Several factors included consistent intervention through video monitoring; the participants were similar in age, development, and social skills, which reduced differences between individuals; and the outcome measures were matched to what the intervention aimed to improve. However, the small number of participants limits how widely the results can be applied; a larger sample in future studies is recommended to confirm our findings.

These strengths are particularly relevant for extending autism services to underserved communities in low- and middle-income countries, where access to trained professionals and specialized resources (41) may be limited. The current study demonstrates a cost-efficient, caregiver-mediated intervention that can be delivered with minimal professional support. The promising outcomes suggest that this approach could help to reduce disparities in ASD care and improve social skills and quality of life for children with ASD in Thailand and other middle-income nations (42,43).

However, several limitations, including a modest sample size and short-term follow-up period, limit the conclusions that can be drawn about the intervention’s long-term effectiveness and generalizability. The reliance on caregiver-reported outcomes, while providing valuable insights into children’s social behaviors in naturalistic settings, may be subject to bias.

We recommended that future studies incorporate blinded third-party raters (e.g., teachers or clinicians) and standardized behavioral assessments to triangulate findings, as well as use larger, more diverse samples, longer-term follow-up assessments, and multi-modal outcome measures (18,19). The inclusion of standardized diagnostic assessments, blinded clinician ratings, and direct behavioral observations would provide a more comprehensive and objective evaluation of the intervention’s effects (42). Collecting data on implementation fidelity, engagement, and family experiences could yield valuable insights into the key ingredients and optimal delivery (43) of the intervention.

This study offers initial support for the acceptability and efficacy of a caregiver-delivered e-book Social Stories intervention for improving social communication skills in Thai preschool children with ASD. The use of an engaging, visually-supported digital storytelling format, implemented by parents in the home, shows promise for increasing access to culturally-relevant, evidence-based ASD interventions in underserved communities. With further research and cross-disciplinary collaboration, technology-assisted Social Stories hold potential to become a practical, scalable tool for empowering families and enhancing social skills and quality of life for children with ASD worldwide.

Conclusions

This RCT provides compelling evidence for the effectiveness of a caregiver-delivered e-book Social Stories intervention in enhancing social communication skills among Thai preschoolers with ASD. The intervention’s efficacy in improving eye contact, greetings, peer interactions, and overall social skills underscores its potential to promote social integration and quality of life.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CONSORT reporting checklist. Available at https://pm.amegroups.com/article/view/10.21037/pm-25-10/rc

Trial Protocol: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-10/tp

Data Sharing Statement: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-10/dss

Peer Review File: Available at https://pm.amegroups.com/article/view/10.21037/pm-25-10/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://pm.amegroups.com/article/view/10.21037/pm-25-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Ethics Board of Queen Sirikit National Institute of Child Health, Thailand (approval No. IRB00007346, July 10, 2023) and informed consent was taken from all individual participants’ parents prior to enrollment in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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