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Autism Spectrum Social Stories in Schools Trial 2 (ASSSIST-2): a pragmatic randomised controlled trial of the Social Stories™ intervention to address the social and emotional health of autistic children in UK primary schools

This randomised controlled trial aimed to establish whether Social StoriesTM are clinically effective and cost-effective in improving social responsiveness and social and emotional health in children on the autism spectrum in schools.

Why did we do this research?

Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental disorder that affects up to 1.6% of children in the UK and has an adverse impact on overall adult outcome. Many children with autism struggle to manage social anxiety, feelings of anger, which this can lead to outbursts of aggression, and social communication difficulties are frequently associated with persistently disruptive behaviour. One intervention that attempts to alleviate these social difficulties whilst not being intrusive, time consuming or requiring extensive involvement of outside experts is Carol Gray’s Social Stories™. Social Stories™ are short stories which describe a social situation or skill to help children with ASD to understand a situation applicable to the child more easily. The current trial aims to establish whether Social Stories™ are clinically and cost-effective in improving child social responsiveness, reducing challenging behaviour and improving social and emotional health in children with ASD in primary schools.

What did we do?

We undertook a multisite pragmatic cluster randomised controlled trial comparing Social Stories™ with care as usual. Two hundred and forty-nine children were randomised via a bespoke system hosted at York Trials Unit (129 Social Stories and 120 care as usual).

The intervention included training for educational professionals and caregivers covering psychoeducation and implementation of Social Stories™. Stories were written around contextualised goals around the child's need for social information. Interventionists read the Social Story™ with the child at least six times over 4 weeks during school.

The primary outcome was the Social Responsiveness Scale-2 completed by teachers at 6 months (the primary end point), which measures social awareness, cognition, communication and behaviour. Data were collected from caregivers and educational professionals at 6 weeks and 6 months through questionnaires.

Who was involved?

Autisitic children aged 4-11 years old in primary schools across Yorkshire and Humber, alongside their parents, teachers and teaching staff took part. In total, 87 schools were randomised including 249 children.

What did we find?

After 6 months, a reduction of 1.61 points was found on the Social Responsiveness Scale-2 in the intervention group (95% CI −4.18 to 0.96, p = .220) and for those who attended at least six sessions a reduction of 3.37 points (CACE 95% CI −6.65 to −0.10, p = .043). Children in the intervention group met their individual socio-emotional goal more frequently than children receiving usual care alone and this was statistically significant. No statistically significant differences were found in other secondary outcomes including anxiety, depression, general health or parental stress.

Social Stories™ represent a low-cost, low-burden intervention. Benefits are seen in individual socio-emotional goals but without clinically evident impact on social responsiveness, anxiety, depression, parental stress or general health.

Publications

  • Wright, B. , Bell, K.J. , Blackwell, J.E.  et al. (2024) Impact of Social Stories on social and emotional health of autism spectrum primary school children: the ASSSIST2 RCT with economic evaluation. Health Technology Assessment, 28 (39). ISSN 1366-5278 https://doi.org/10.3310/JBTM8017
  • Wright, B., Blackwell, J.E., Bell, K.J., et al. (2025), Autism Spectrum Social Stories in Schools Trial 2 (ASSSIST-2): a pragmatic randomised controlled trial of the Social Stories™ intervention to address the social and emotional health of autistic children in UK primary schools. Child Adolesc Ment Health, 30: 4-12. https://doi.org/10.1111/camh.12740
  • Wang H-I, Bell K, Blackwell J, et al. Cost–utility analysis of Social StoriesTM for children with autism spectrum disorder in mainstream primary schools: results from a randomised controlled trial. BJPsych Open. 2024;10(4):e123. https://doi.org/10.1192/bjo.2024.47

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Team

Department of Health Sciences, University of York, York

  • Dr Arabella Scantlebury University of Birmingham
  • Leah Attwell, COMIC, LYPFT
  • Dr Catarina Teige, COMIC, LYPFT
  • Hayley Carrick, COMIC, LYPFT
  • Amelia Taylor, COMIC, LYPFT
  • Rachel Hodkinson, COMIC, LYPFT
  • Hannah Edwards, COMIC, LYPFT
  • Hannah Pearson, COMIC, LYPFT
  • Rebecca Hargate, COMIC, LYPFT
  • Anne Mclaren, PPI Representative

 

Funding

The research was funded by NIHR Health Technology Assessment (Award ID: 16/111/91) and a grant of £1,058,348.23 awarded. The project was started in June 2018 and completed in May 2022.

Study Registration

ISRCTN11634810