Social stories beyond autism: preschoolers, ADHD, anxiety and digital formats

Background: why look beyond autism?

Carol Gray introduced social stories in the early 1990s to give autistic pupils accurate information about confusing social situations (Gray & Garand, 1993). Our main review covers that autism evidence. In practice, stories travel much further: nurseries use them for sharing, dentists for first visits, parents for bedtime. The logic, that knowing what will happen makes a hard moment easier, is not specific to autism.

This review asks whether the evidence has followed the practice: for typically developing children, for ADHD, learning disabilities, hearing impairment and anxiety, for screen and video formats, and for Gray's own rules. Her current Social Stories™ 10.3 criteria require, among ten rules, at least three descriptive sentences for every sentence that coaches, and no more than one sentence that coaches the child (Gray, 2021).

How the research has been done

Most studies use single-case designs: one to four children are observed repeatedly before and after a story is introduced. In a multiple-baseline design the story starts at different times for different children; in a reversal (ABAB) design it is introduced, withdrawn and reintroduced. If behaviour changes each time the story arrives, and only then, the story probably caused it. Methodological reviews check whether studies show this "functional relation" (Leaf et al., 2015).

Syntheses use overlap statistics. Tau-U compares every measurement before the story with every measurement after it, correcting for any existing trend; higher values mean a clearer effect (see our glossary). Group studies are few: a handful of randomised controlled trials (RCTs), those outside autism mainly in dentistry, and some non-randomised controlled studies. Outcomes range from observed behaviour to teacher ratings and plaque scores. Social validity studies ask whether parents, teachers and children find the goals, methods and results worthwhile.

What the reviews and trials found

The newest syntheses (2020 to 2026)

Single-case meta-analysis. Guo and colleagues pooled 21 single-case studies with 61 autistic participants and found an overall Tau-U of 0.743, which they describe as moderate (Guo et al., 2026). The abstract highlights school-aged children, but in the full paper none of the subgroup differences (age, skill area, digital versus paper, who delivered the story, gender) was statistically significant. Only studies reporting adherence to Gray's guidelines were included, and 18 of 21 were rated at moderate risk of bias.

Preschool review. Zhou and colleagues reviewed 21 studies of children aged 2 to 6, typically developing or with autism, developmental delay, hearing impairment or ADHD, targeting toothbrushing, peer interaction, staying on task, self-regulation, sleep and aggression (Zhou et al., 2024). Most reported improvements, but 16 had only one to three children, and 17 involved autistic children. Only two trials could be pooled: children shown social stories practised more toothbrushing steps than those given conventional instruction (mean difference 0.66 steps, 95% CI 0.30 to 1.02).

Young children with challenging behaviour. A meta-analysis of 12 single-case studies with 30 children aged 3 to 5, judged against What Works Clearinghouse standards, found that rigour and effects varied widely, whether stories were used alone or combined with other approaches, and called for more studies of stories as the primary intervention (Wahman et al., 2022).

Scoping review. Of 56 studies from 2007 to 2018, most but not all reported benefits, for behaviours from aggression to following directions; most were single-subject designs (Como et al., 2024).

Older reviews and critical appraisals

Earlier reviews are cautious. Rust and Smith found positive results but no study meeting comprehensive, stringent standards (Rust & Smith, 2006). Of six controlled trials, five reported significant social benefits, with maintenance and generalisation unclear (Karkhaneh et al., 2010). Styles argued that social stories could not yet be recommended as a stand-alone evidence-based practice (Styles, 2011). A review of seven studies of disruptive behaviour found variable success, unplanned teacher prompting muddying results, and very few studies outside autism (Rhodes, 2014).

Methodological reviews are sharper. Of 41 studies, most showed only a partial or no clear demonstration that the story caused the change (Leaf et al., 2015), and an update found continuing weaknesses (Milne et al., 2020). In a head-to-head comparison with six autistic young people, the teaching interaction procedure (explanation, demonstration and role play with feedback) led to mastery of 18 of 18 skills, social stories 4 of 18 (Leaf et al., 2012); a three-child replication agreed (Kassardjian et al., 2014).

Typically developing children and preschoolers

With three four-year-olds in a Head Start preschool, stories compared with a neutral book gave some support for less aggression and more positive peer play (Benish & Bramlett, 2011). When parents of 19 children without autism were coached to write stories following Gray's guidelines, disruptive behaviour fell and constructive behaviour rose in 15 of 19 cases (79%) (Gullón-Rivera et al., 2019). But with 32 preschoolers with and without disabilities, taught in groups of four, neither story-only nor story-plus-practice versions were effective (More et al., 2013).

At bedtime, four children aged 2 to 7 with marked bedtime problems received "The Sleep Fairy", a story setting out expectations, with small rewards. Disruptive bedtime behaviour fell by 78% on average, maintained at three months, and parents rated it highly acceptable (Burke et al., 2004); the story's own share is unknown.

In dentistry, an RCT with 100 children aged 3 to 5 compared a custom story showing the real clinic and dentist with a ready-made one. Anxiety fell in both groups. The authors favoured the custom story, but the between-group p-value in the abstract (0.803) is not significant (Kaavya et al., 2026). For preschoolers with special healthcare needs, a 24-month RCT with 306 children found no difference in tooth decay but better oral hygiene and toothbrushing, and more dental visits (odds ratio 2.00, 95% CI 1.15 to 3.49), than standard leaflets (Zhou et al., 2020a). A non-randomised companion study of 181 special-care preschoolers found gains with and without autism, linked to intellectual functioning and parents' attitudes (Zhou et al., 2020b).

ADHD, learning and intellectual disabilities, hearing impairment and anxiety

Learning and intellectual disabilities. The strongest study outside autism is a controlled comparison, not described as randomised, of 63 children with learning disabilities: those who heard an audio-recorded story twice a week for a month chose more positive ways of resolving conflict and were rated by teachers as behaving more appropriately, after the intervention and at follow-up (Kalyva & Agaliotis, 2009). Single-case studies report less disruption in three secondary students with severe intellectual disabilities using tablet stories (Kim et al., 2014), gains in classroom social skills (please, thank you, hand raising) with stories alone (Piper et al., 2024), and better mealtime skills when stories preceded video modelling (Nosrati et al., 2025). A case study used a story within a behavioural plan for a boy's sleep problem (Moore, 2004).

Hearing impairment. With two four-year-olds with cochlear implants, one child's spoken comments rose moderately to highly, the other's slightly (Raver et al., 2013). With deaf and hard-of-hearing autistic pupils, stories with American Sign Language vocabulary had no immediate effect (Kwon et al., 2023).

ADHD and behaviour difficulties. We found no controlled trial of social stories for children with ADHD; they appear only within mixed samples (Zhou et al., 2024). The closest evidence is discouraging: for five pupils at risk of emotional and behavioural disorders, stories did not improve engagement, whereas visual supports did (Zimmerman et al., 2020).

Anxiety. Outside dentistry, evidence is sparse. Before a summer camp, digital stories for ten autistic children were followed by teacher-rated drops in anxiety and better understanding, with medium to large effects but no control group (Smith et al., 2021). See also our reviews of school anxiety and medical and dental preparation.

Digital, video and combined formats

A pilot RCT compared digital stories (9 autistic children) with a digital poem (6 children) and found behaviour benefits lasting to a six-week follow-up (Hanrahan et al., 2020). Data from 856 app users showed adult-rated progress was highest for younger, more verbal children (Camilleri et al., 2023).

Screen and paper versions perform similarly. PowerPoint worked slightly better than paper for three pupils (Mancil et al., 2009); two adolescents improved with both formats but preferred technology (Anthony & Bobzien, 2022); iPad stories helped one of three four-year-olds (Vandermeer et al., 2015). In the 2026 meta-analysis, digital stories scored a Tau-U of 0.64 and paper 0.58, a non-significant difference (Guo et al., 2026).

Video versions are often combined with video modelling. Video stories matched to the reason for each pupil's behaviour increased engagement for four middle-school pupils (Cihak et al., 2012); a videotaped story with adult models improved two of three conversation skills in one boy (Scattone, 2008); computer-presented stories plus video models improved social communication in three children, though two needed added rewards and only one generalised (Sansosti & Powell-Smith, 2008). Self-modelling videos with stories helped a nine-year-old recognise emotions, in a weak AB design (Bernad-Ripoll, 2007), and a three-year-old learn to greet and invite peers to play (Litras et al., 2010). In such packages the story's own contribution cannot be separated (Milne et al., 2020).

For whom and under what conditions

Language matters more than the label

Across studies, language comprehension appears to predict benefit better than diagnosis. Parents of 17 autistic children judged stories (with comic strip conversations) effective for 13 (76.5%), and the only predictor was a verbal mental age of at least about three years (Hutchins & Prelock, 2013a). In an RCT with 45 autistic children aged 7 to 14, stories helped those with game experience and verbal comprehension in the borderline range or above (Quirmbach et al., 2009). App and dental studies agree: younger, more verbal children and those with higher intellectual functioning gained most (Camilleri et al., 2023); (Zhou et al., 2020b).

Who delivers and what else is included

Who reads the story did not significantly change effects in the 2026 meta-analysis (Guo et al., 2026), and earlier work found stories worked better when read shortly before the situation by the child or a familiar adult (Kokina & Kern, 2010). Parents can write and use stories with little researcher input, and results were better when they consulted their child on goals (Camilleri et al., 2024). Many studies add rewards, role play, practice or video; the one group study of stories alone with preschoolers found no effect (More et al., 2013).

Does following Gray's criteria matter?

A systematic review for the UK trial programme found that most studies either did not follow established Social Story criteria or did not report whether they did (Wright et al., 2016), and the preschool review found inconsistent story-writing methods (Zhou et al., 2024). So it is often unclear what was actually tested. Direct tests are rare: in one RCT, standard and more directive stories were equally effective (Quirmbach et al., 2009). Of 82 free online needle stories, most followed some of Gray's guidelines (90% had meaningful titles), but few allowed customisation (Dobson et al., 2025). Adherence matters for interpreting research; whether strict adherence improves outcomes is largely untested. The largest trial, using Gray's approach with trained staff, found gains on individual goals rather than broad social measures (Wright et al., 2024).

What parents and teachers think

Social validity is generally good but varies. Parents rated 11 of 17 behaviour stories (64.7%) and 10 of 19 communication stories (52.6%) effective (Hutchins & Prelock, 2013b). Mothers felt more competent with digital stories (Camilleri et al., 2021); teachers and pupils liked PowerPoint and video formats (Mancil et al., 2009); (Cihak et al., 2012). Of dental specialists, 72% found stories useful, but perceived benefit fell from 94% for autistic patients needing least support to 44% for those needing most (Zafar et al., 2025). Liking is not evidence of effect, and raters usually knew a story was in use.

What this means in practice

• Think language, not diagnosis. A story is most likely to help a child who can follow and talk about a short spoken story (Hutchins & Prelock, 2013a).
• Pair the story with doing. For young children, combine it with practice, praise or a small reward; a story alone may not be enough (More et al., 2013); (Burke et al., 2004).
• Screens are fine. Digital stories work about as well as paper (Guo et al., 2026), and in small studies children preferred them (Mancil et al., 2009); (Anthony & Bobzien, 2022).
• Check any story you download. It should describe more than it directs, use literally accurate wording and show accurate steps (Gray, 2021); (Dobson et al., 2025).
• Measure one behaviour. If nothing changes within a few weeks, try a different goal or approach; role play with feedback or visual supports may suit some children better (Leaf et al., 2012); (Zimmerman et al., 2020).
• Know when to get help. Persistent sleep problems, aggression or anxiety that disrupts daily life deserve a talk with a GP, health visitor or the school's SENCo.

What this means for short personalised cartoons

Some findings plausibly carry over to short animated stories. Packages combining a story-like explanation with a model succeeding have positive single-case results (Litras et al., 2010); (Nosrati et al., 2025), screen delivery is acceptable to families, and reading shortly before the moment matters. The links between watching and learning are covered in our reviews of video modelling and personalisation.

Much does not carry over. No study has tested a short cartoon in which an animated version of the child plays the lead. Most evidence comes from autistic children with an adult reading, asking questions and adding rewards; passive viewing lacks those ingredients. The only trial of a custom versus ready-made story found no clear difference (Kaavya et al., 2026). Our personalised cartoons draw on this research but have not been tested, and they are preparation, not treatment.

Limits of the evidence

• Most studies involve one to three children, and most involve autistic children, even in reviews of preschoolers (Zhou et al., 2024).
• RCTs are few, and those outside autism are mainly in dentistry, far from everyday social life.
• Stories are usually bundled with rewards, practice or video, so their own contribution is unclear (Milne et al., 2020).
• Ratings often come from parents or teachers who know a story is in use.
• Adherence to Gray's criteria is rarely reported (Wright et al., 2016).
• Some reports contain internal inconsistencies, such as conclusions that go beyond the reported statistics (Kaavya et al., 2026).

Open questions for research

1. In a cluster RCT in nurseries, does a story about one shared moment (such as drop-off) reduce observed distress compared with a neutral picture book, rated by blinded observers?
2. For children with ADHD, do social stories add anything to visual supports or self-monitoring for on-task behaviour?
3. In component analyses, what does the story add over video modelling alone for the same skill?
4. Do stories that meet the 10.3 criteria (at least three descriptive sentences per coaching sentence) outperform directive stories for children aged 4 to 7?
5. Does receptive language age predict benefit across diagnoses, and is there a usable threshold?
6. Within digital formats, do narration, animation or interactivity improve outcomes over a static on-screen page?
7. Do effects last beyond three months and change outcomes families value, such as completed dental visits?
8. In an adequately powered RCT, is a personalised story better than a well-made generic one?

Frequently asked questions

References

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Spotted an error, or know a study we should add? Email hello@calalunakids.com. Every study we draw on is in the research library; research terms are explained in our methods glossary.