Effectiveness of Structured Storytelling on Social Skills and Social Adaptation in Hospitalized Children with Chronic Illnesses: A Quasi-Experimental Study

Effectiveness of Structured Storytelling on Social Skills and Social Adaptation in Hospitalized Children with Chronic Illnesses: A Quasi-Experimental Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effectiveness of Structured Storytelling on Social Skills and Social Adaptation in Hospitalized Children with Chronic Illnesses: A Quasi-Experimental Study Maryam Abadar, Afsaneh Beiranvand, Seyedeh Fatemeh Ghasemi, Rasool Mohammadi, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8104834/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Children with chronic illness frequently experience challenges in social adaptation due to prolonged hospitalization, pain, and reduced opportunities for peer interaction. Storytelling has been introduced as a psychosocial intervention that may enhance social skills through emotional engagement, modeling, and symbolic problem-solving. The present study aimed to evaluate the effectiveness of a structured storytelling program on improving social skills in hospitalized children with chronic disease. Methods This quasi-experimental study included 60 hospitalized children with chronic illness aged 6–10 years in Behbahan, Khuzestan, Iran. Participants were randomly assigned to the intervention (n = 30) or control (n = 30) group. The intervention group received eight 45-minute storytelling sessions over four consecutive days alongside routine care; the control group received routine care only. Social skills were assessed using the Social Skills Rating System (SSRS) and social adaptation by Dokhanchi’s Child Social Adaptation Scale before and after the intervention. Data were analyzed using appropriate statistical tests to compare total and subscale scores between groups. Results Post-intervention, the storytelling group demonstrated significant improvements in self-adaptation (p = 0.001), family adaptation and peer adaptation (p < 0.001) compared with controls. The total SSRS score increased significantly in the intervention group compared to the control group (p < 0.001). Subscale analysis revealed the greatest improvements in assertion and cooperation, followed by responsibility, while self-control showed the smallest but still significant increase (p = 0.041). No significant changes were observed in the control group. Conclusion Structured storytelling is a low-cost, non-pharmacological, culturally appropriate intervention that enhances social adaptation and social skills particularly assertion, cooperation, and responsibility among hospitalized children with chronic illnesses. Integrating storytelling into pediatric care may reduce psychosocial burdens and support social growth. Longer-term interventions are recommended for sustained outcomes. student in pediatrics nursing. Student Research Committee School of Nursing and Midwifery Lorestan University of Medical Sciences Khorramabad Iran. [email protected] Figures Figure 1 Introduction Over recent decades, a notable shift has occurred in pediatric health trends, marked by a substantial rise in the prevalence of chronic diseases among children and adolescents[ 1 , 2 ]. Whereas infectious conditions once dominated the burden of disease in this population, chronic diseases now account for a significant portion of long-term health concerns[ 3 , 4 ]. Clinically, chronic diseases are commonly defined as a condition that persists for at least three months annually and requires continuous medical management or restricts a child’s everyday functioning[ 5 ]. Disorders such as anemia, cerebral palsy, thalassemia, epilepsy, diabetes, chronic respiratory conditions, hemophilia, neuromuscular diseases, and childhood cancers represent some of the most frequent chronic conditions in this age group[ 6 ]. Chronic illnesses can disrupt normative developmental trajectories and interfere with children’s ability to participate fully in social contexts, leading to difficulties in social competence and interpersonal functioning [ 7 ]. Social skills refer to the set of learned behaviors that enable individuals to interact effectively with others in a variety of social contexts; these include cooperation, assertion, self-control, empathy, and communication[ 8 , 9 ]. Children who lack adaptive social skills often experience peer rejection, social withdrawal, or maladaptive social responses, which can undermine their psychosocial functioning and overall well-being[ 10 ]. Difficulties in social competence and adjustment may manifest as poor interaction with peers, reduced participation in group activities, and challenges in communicating needs and emotions effectively [ 11 ]. Such challenges not only affect children’s current functioning but can also persist into adolescence and adulthood, influencing academic engagement, community participation, and quality of life [ 12 ]. Given the foundational role of social skills in adaptive functioning, early identification and intervention targeting these competencies are crucial. Interventions that enhance social skills can reduce problematic behaviors, improve peer relations, and strengthen adaptive responses in social contexts[ 13 , 14 ]. Mental health holds equal importance to physical health in childhood[ 15 ], yet these children frequently face additional burdens due to repeated hospitalizations, which may further contribute to emotional and behavioral disturbances[ 16 ]. Hospitalization itself can be a distressing experience for children. The unfamiliar environment, separation from caregivers, and concerns related to illness often provoke anxiety, sadness, fear, and withdrawal, all of which can impede healthy social development[ 15 , 17 ]. Social development constitutes a fundamental process through which children learn to interact, form meaningful relationships, and regulate their behavior. This developmental domain includes peer and adult interactions, comprehension of social norms, and acquisition of critical skills such as empathy, cooperation, and effective communication[ 18 ]. On the other hand, chronic childhood diseases elevate the risk of emotional and behavioral difficulties, which may manifest as poor treatment adherence, maladaptive social behaviors, and reduced social competence[ 19 ]. Consequently, early interventions that specifically address maladaptive behaviors can substantially enhance children’s emotional, behavioral, and social outcomes[ 20 ]. While pharmacological treatments address the physical dimensions of chronic illness, non-pharmacological interventions aimed at enhancing social and emotional functioning have gained attention for their potential to improve psychosocial outcomes[ 21 , 22 ]. Common approaches to enhancing social competencies in children include structured social skills training, cooperative play interventions, role-plays, and reciprocal dialogue activities[ 23 ]. Among emerging strategies, storytelling therapy or narrative-based interventions offers a simple, low-cost option that can be implemented even by nurses in pediatric wards[ 8 ]. For example, the study conducted by Nuray Macuncu and Melahat Akgun Kostak (2025) showed that incorporating storytelling and drawing during inhalation therapy helped reduce children’s fear and negative emotions and increased parental satisfaction compared with standard routines[ 24 ]. Similarly, research by Yousefi and colleagues on 330 hospitalized children with leukemia demonstrated that storytelling significantly alleviated their pain levels [ 25 ]. Among emerging strategies, storytelling therapy or narrative-based interventions offers a creative, child-friendly, and low-cost option that can be implemented in clinical and educational settings to facilitate social learning[ 8 ]. Storytelling engages children in reflective thinking, encourages perspective taking, and provides opportunities for rehearsal of social responses in safe, vicarious contexts[ 9 ]. Such findings underscore the promise of structured storytelling in fostering core social competencies. Although existing evidence highlights the potential benefits of storytelling for children’s development, a considerable gap remains regarding its specific effects on social skills and social adjustment among children with chronic illnesses, especially in clinical or hospital settings[ 8 , 26 ]. Current literature indicates that intervention studies focused on enhancing social competencies in this population are limited, despite the clear importance of these outcomes. Considering the continued high prevalence of chronic diseases among children — who represent a vital societal resource — greater attention to psychological and non-pharmacological interventions targeting social adaptation and competence is warranted[ 27 ]. School-age children (6–10 years) are naturally inquisitive, exploratory, and learn much of their social competencies through interaction and narrative engagement, making structured storytelling an appealing and developmentally appropriate intervention for this group[ 23 ]. Accordingly, the present study was designed to examine the impact of structured storytelling intervention on social skills and social adjustment among hospitalized children aged 6 to 10 years with chronic diseases. Methods Study Design and Setting This study was conducted between 2020 and 2022, as a quasi-experimental interventional study involving 60 hospitalized children aged 6 to 10 years in the pediatric departments of the educational–medical centers of Behbahan, Khuzestan, Iran. Sample Size Determination The sample size was calculated based on the findings of Homai et al. (2015) [ 28 ]. Considering a significance level of α = 0.05, a statistical power of 90%, and the reported means and standard deviations of social adaptation scores in the intervention and control groups (17.54 ± 3.81 and 13.54 ± 4.57, respectively), the required sample size for each group was estimated as 17 participants using the formula for comparing two means. Accounting for a potential attrition rate of 20%, the final sample size was increased to 30 participants per group, using the following formula: $$\:\frac{({z}_{1-\frac{a}{2}}+{z}_{1-\beta\:}{)}^{2}({\delta\:}_{1}^{2}+{\delta\:}_{2}^{2})}{({\mu\:}_{1}-{\mu\:}_{2}{)}^{2}}$$ $$\:\frac{(1.96+0.84{)}^{2}({3.81}_{}^{2}+{13/54}_{}^{2})}{(17.54+13/54{)}^{2}}=30$$ Inclusion and Exclusion Criteria Inclusion criteria consisted of: children aged 6–10 years (school age); a confirmed diagnosis of at least one chronic illness (e.g., hemophilia, anemia, cancer, epilepsy and seizures, cardiovascular diseases, chronic respiratory infections, or diabetes); obtaining verbal and written informed consent from parents; willingness of both parents and the child to continue participation throughout the study; and living with both biological parents. Exclusion criteria included: withdrawal or unwillingness of the child or parents at any stage; discharge before completion of the intervention sessions; voluntary early discharge; development of a new acute illness; exacerbation of the underlying disease; or the child's death during the study period (Fig. 1 ). Sampling and Randomization Sampling was performed using a convenience approach among eligible hospitalized children (conducted by the first author). Randomization followed a permuted block method using 15 four-person blocks to ensure balanced allocation across groups. Within each block, all six possible permutations of assigning two participants to the intervention group (A) and two to the control group (B) were generated: AABB, ABAB, ABBA, BBAA, BABA, and BAAB. These block sequences were placed into sealed envelopes by the second author—who remained blinded to the allocation—and then provided to the first author. Each time a participant entered the study, one envelope was randomly selected (with replacement), and children were assigned to their respective groups based on the sequence indicated. Enrollment continued until the target sample size was achieved. In this study, both the participants and the interventionist (first author) were aware of group assignments, whereas the biostatistician remained blinded. Data Collection Instruments Demographic Questionnaire A demographic information form was used to collect background characteristics of participants, including the child’s gender, mode of delivery, mother’s educational level, birth order, type of chronic disease, family history of genetic disorders, maternal age at childbirth, child’s chronological age, and duration of hospitalization. The face validity of the form was assessed by ten nursing faculty members and confirmed based on clarity and relevance of items. Social Skills Rating System (SSRS) Social skills were assessed using the Social Skills Rating System (SSRS) developed by Gresham and Elliott (1990), a norm-referenced instrument designed to evaluate social behaviors and problem behaviors among preschool and school-aged children[ 29 ]. The SSRS includes three parallel forms (parent, teacher, and student), of which the parent form was used in this study. The parent form contains 34–57 items scored on a 3-point Likert scale (0 = never, 1 = sometimes, 2 = very often), measuring five subscales: cooperation, assertion, responsibility, empathy, and self-control[ 30 ]. Subscale scores are summed to generate standardized scores and percentile ranks based on normative samples. The SSRS has demonstrated strong psychometric properties, with internal consistency reported at α = 0.90 for the Social Skills scale, and test–retest reliability of 0.80 for parent ratings in elementary-aged children. The Persian version of SSRS has been translated, culturally adapted, and validated in Iranian children, showing acceptable reliability with Cronbach’s alpha of α = 0.87, indicating good internal consistency. The version standardized for Iranian preschool children by Shahim (2005) demonstrated satisfactory construct validity and has been recommended for evaluating cooperation, assertion, self-control, and responsibility[ 31 ]. In the present study, the questionnaire was completed as a parent-report form by one of the caregivers. Children’s Social Adaptation Scale The Children's Social Adaptation Scale, developed by Dokhanchi (1998), assesses social adaptation through 37 four-point Likert items (never, rarely, sometimes, often), completed by parents (typically the mother) [ 32 ]. Adaptation-related items are scored from 0 (never) to 3 (often), while maladaptive items are reverse-scored. Total scores range from 0 to 111 and are categorized into five levels: very low ( 90). Reliability reported for this scale includes split-half and Cronbach’s alpha coefficients of 0.79 and 0.72, respectively, and a criterion validity of 0.81. Mahmoudi et al. reported a Cronbach’s alpha of 0.81, indicating acceptable internal consistency [ 33 ]. Intervention In this study, participants in the intervention group, in addition to receiving routine/standard pediatric care, participated in an eight-session storytelling therapy program. The intervention was delivered over four consecutive days, with two 45-minute sessions per day, conducted by the primary researcher, who had previously completed specialized training in storytelling and obtained certified accreditation from authorized institutions. The content of the stories was selected and standardized with the approval of storytelling instructors and experts from the Children’s Intellectual Development Center. Sessions were held in the afternoon and evening, coordinated with ward staff and following renewed informed consent from both parents and children. During each session, the researcher actively engaged children using professional storytelling techniques, including the use of puppets, drawing, body language, changes in tone and voice, strategic pauses (suspense), and predictive questioning to anticipate story developments. These strategies aimed to enhance attention, problem-solving skills, and social competence.The control group received only standard hospital care without additional educational or story-based interventions. The stories were drawn from reputable sources, including “Ay Ghesseh Ghesseh Ghesseh” and “Storytelling” by Dr. Arthur Roshan (e.g., “When Everyone Gets There” and “Fingiliha” ), which had previously been shown to reduce anxiety in children. Additionally, stories by notable Iranian authors such as Mostafa Rahman Doost, Farhad Hassanzadeh, Sarvar Pouria (scientific stories), Sosan Taqdis, Mehdi Mirkiani, and collections such as “365 Stories” and “My Hero is You” were included. Story selection was age-appropriate, with narratives that were realistic, concise, and featured a clear plot. Story protagonists typically faced challenges or limitations (similar but not identical to the child’s condition) and resolved problems by leveraging personal abilities, family support, and social skills. The purpose was to foster children’s self-confidence, problem-solving abilities, emotional regulation, and social competence. The storytelling content included themes such as improving quality of life during hospitalization, practicing self-care behaviors (e.g., recognizing when to use inhalers), and developing skills related to the child’s healthy roles (such as engaging in structured activities). Additionally, the stories incorporated health-promoting skills, coping and compensation strategies, narratives of heroes with physical conditions, and messages emphasizing that illness is not the child’s fault, that strength comes from within, and that children with chronic illnesses are no different from healthy peers in their ability to pursue their goals. Questionnaires were administered on the first day of hospitalization and again on the tenth day. Parents completed demographic forms and the Social Development and Children’s Social Adaptation Scales before the intervention, and post-intervention assessments were also completed by parents in both groups. Data collection was conducted exclusively by the lead researcher, with no involvement from other authors. Participants were given 20–30 minutes to complete the instruments independently, after which the researcher reviewed all responses for completeness and prompted participants to address any missing items. No participant dropout or missing data occurred during the study. Statistical Analysis Descriptive statistics, including mean, standard deviation, frequency, and percentage, were used to summarize data. The Shapiro–Wilk test assessed normality assumptions. For between-group comparisons, the chi-square test and Fisher’s exact test were applied to categorical variables, while independent t-tests were used for continuous variables. Given normal data distribution, independent t-tests were employed to compare group means. All analyses were conducted using SPSS version 25, with a significance level set at p < 0.05. Results The demographic characteristics of participants were comparable across the intervention and control groups. In both groups, the majority of children were male (66.7% in the intervention group vs. 60% in the control group). Mode of delivery was similar, with approximately half of the children in each group born via vaginal delivery. Regarding maternal education, the largest proportion in both groups had a high school diploma or lower (56.7% in the intervention group vs. 50% in the control group). Birth order distribution was also comparable, with 86.7% of children in both groups having a birth order of two or lower. The presence of a family history of genetic conditions was nearly identical across groups. In terms of chronic illness type, cystic fibrosis and asthma were the most prevalent in both groups, and the overall distribution of disease types did not differ significantly between groups. No statistically significant differences were observed between the intervention and control groups for any demographic or clinical variables (P > 0.05), indicating baseline homogeneity between groups (Table 1 ). Table 1 Baseline characteristics of participants (n = 60). Characteristics Groups P-value* Intervention (n = 30) n (%) Control (n = 30) n (%) Gender Male 20 (66.7) 18 (60) 0.789 Female 10 (33.3) 12 (40) Mode of Delivery Vaginal 13 (43.3) 15 (50) 0.796 Cesarean 17 (56.7) 15 (50) Maternal Education High school or lower 17 (56.7) 15 (50) 0.606 Associate degree or higher 13 (43.3) 16 (53.3) Birth Order ≤ 2 26 (86.7) 26 (86.7) 0.999 > 2 4 (13.3) 4 (13.3) Genetic History Yes 17 (56.7) 18 (60) 0.999 No 13 (43.3) 12 (40) Chronic Diseases Cystic Fibrosis 9 (30) 10 (33.3) 0.718 Hypothyroidism 5 (16.7) 5 (16.7) Asthma 5 (16.7) 7 (23.3) Epilepsy 4 (13.3) 5 (16.7) Other 7 (23.3) 3 (10) *Fisher’s exact test Prior to the intervention, no significant differences were observed between the groups regarding the mean scores of self-adaptions, family adjustment, and peer adjustment (P > 0.05). However, following the intervention, children in the intervention group demonstrated significantly higher scores across all domains of social adaption compared with the control group. The mean score of self-adaptions increased significantly in the intervention group compared with the control group after the intervention (P = 0.001). Similarly, family adaption scores showed a significant post-intervention improvement in the intervention group (P < 0.001). Although pre-intervention peer-adjustment scores were comparable between the two groups, a significant improvement was observed in the intervention group following the storytelling program (P < 0.001). Overall, the storytelling intervention led to meaningful enhancements in all dimensions of social adjustment (self, family, peers) among children in the intervention group compared with controls (P < 0.001) (Table 2 ). Table 2 Comparison of mean scores of social adaptions and its dimensions before and after the intervention in the intervention and control groups. Variable Groups N Mean (SD) P-value* Coping with Self (Before) Intervention 30 21.50 (3.53) 0.416 Control 30 22.23 (3.40) Coping with Self (After) Intervention 30 25.10 (3.23) 0.001 Control 30 22.33 (3.16) Difference (Before–After) Intervention 30 3.60 (2.14) < 0.001 Control 30 0.10 (0.61) Coping with Family (Before) Intervention 30 21.20 (3.58) 0.421 Control 30 20.57 (2.34) Coping with Family (After) Intervention 30 25.20 (2.89) < 0.001 Control 30 21.03 (2.00) Difference (Before–After) Intervention 30 4.00 (2.39) < 0.001 Control 30 0.47 (1.00) Coping with Peers (Before) Intervention 30 22.20 (3.10) 0.370 Control 30 24.03 (3.55) Coping with Peers (After) Intervention 30 25.55 (2.82) 0.170 Control 30 24.46 (3.11) Difference (Before–After) Intervention 30 3.33 (2.46) < 0.001 Control 30 0.43 (1.22) Total Social adaption (Difference Before–After) Intervention 30 11.37 (5.87) < 0.001 Control 30 1.00 (2.03) *Independent samples t test The total SSRS score increased significantly in the intervention group compared to the control group (Mean difference = + 13.50, p < 0.001). Analysis of the SSRS subscales revealed that structured storytelling had the greatest effect on assertion and cooperation, a moderate effect on responsibility, and the smallest improvement in self-control, although still statistically significant (p = 0.041). No significant changes were observed in the control group across any domains. These findings indicate that the eight-session storytelling program effectively enhanced multiple components of social skills in children with chronic illness Table 3 Comparison of mean scores of Total Social Skills Score (SSRS) before and after the intervention in the intervention and control groups. variable Group N Mean ± SD Before Mean ± SD After Mean Diff *P-value Total Social Skills Score (SSRS) Control 30 43.10 ± 5.90 44.20 ± 6.00 + 1.10 0.278 Intervention 30 42.30 ± 6.10 55.80 ± 5.70 + 13.50 < 0.001 * Independent samples t test After the intervention, the total social skills score increased significantly in the intervention group (p < 0.001), while no noticeable change was observed in the control group. Table 3 Comparison of mean scores of SSRS Subscales before and after the intervention in the intervention and control groups. Variable Groups N Mean (SD) Befor Mean (SD) After Mean Diff P-value* Assertion (Self-expression) Intervention 30 10.80 ± 2.90 15.60 ± 3.10 + 4.80 < 0.001 Control 30 11.10 ± 3.00 11.50 ± 2.80 + 0.40 0.412 Cooperation Intervention 30 11.50 ± 2.70 15.20 ± 2.50 + 3.70 < 0.001 Control 30 11.30 ± 2.90 11.90 ± 3.10 + 0.60 0.331 Responsibility Intervention 30 9.90 ± 2.40 12.60 ± 2.50 + 2.70 0.002 Control 30 10.20 ± 2.30 10.60 ± 2.40 + 0.40 0.368 Self-control (Emotional regulation Control Intervention 30 10.10 ± 2.60 ) 11.30 ± 2.40 + 1.20 0.041 Control 30 10.40 ± 2.50 10.70 ± 2.30 + 0.30 0.502 * Independent samples t test Following the intervention, the total SSRS score increased significantly in the intervention group compared to the control group (Mean difference = + 13.50, p < 0.001). Analysis of the SSRS subscales revealed that structured storytelling had the greatest effect on assertion and cooperation, a moderate effect on responsibility, and the smallest improvement in self-control, although still statistically significant (p = 0.041). No significant changes were observed in the control group across any domains. These findings indicate that the eight-session storytelling program effectively enhanced multiple components of social skills in children with chronic illness. Discussion his study aimed to evaluate the impact of storytelling therapy on the social development and social adaptation of children living with chronic diseases. The findings of the present study demonstrated that implementing a storytelling therapy program resulted in significant improvements across all dimensions of social adaptation—including self-adjustment, family adjustment, and peer adjustment—as well as enhanced social development among hospitalized children with chronic illnesses. While no significant differences existed between the groups before the intervention, the eight-session storytelling program produced notable post-intervention improvements in the intervention group compared with the control group. Among the chronic conditions, hypothyroidism, asthma, epilepsy, and cystic fibrosis were the most prevalent in both groups. These results underscore the positive impact of storytelling as a low-cost, psychosocial intervention that is feasible for hospital settings. The present findings are consistent with previous study. Ajorloo et al. reported that storytelling reduced anxiety and improved sleep habits among children with cancer undergoing chemotherapy [ 34 ]. Similarly, Gonçalves et al. found that both massage and storytelling were effective strategies for reducing aggression by enhancing shared experiences and social interaction; children exposed to stories identified with characters and achieved higher levels of social adaptation [ 35 ]. Homai et al., in a study of 40 children aged 4 to 6 years, also demonstrated that storytelling-based instruction improved behavioral adjustment and emotional regulation, suggesting that greater adjustment enhances the capacity for self-regulation [ 28 ]. Hakim et al. (2008) similarly reported reductions in anxiety and increased psychological safety among hospitalized children exposed to storytelling [ 16 ]. Furthermore, Timberlake (2000) and Timberlake et al. (2023) have shown the efficacy of story-based and cognitive–behavioral interventions in improving social skills, emotional regulation, and reducing maladaptive behaviors [ 22 ]. The consistency across studies likely stems from the engaging, interactive, and non-threatening nature of storytelling, which encourages active participation and facilitates social learning. Storytelling provides a symbolic and safe environment that allows children to indirectly process personal and social challenges. Story characters often encounter difficulties similar to those faced by the child, and overcome them through social skills, family support, and problem-solving. Identifying with such characters enhances self-confidence, emotional understanding, and adoption of appropriate behavioral patterns. This aligns with findings by Compas et al. (2012), who emphasized that coping strategies learned in childhood play a major role in subsequent social and psychological adjustment [ 19 ]. The results further indicate that storytelling not only improves individual adjustment but also enhances interactions with family members and peers (see Table 1 ). Since prolonged hospitalization restricts peer interaction and may lead to social isolation, implementing storytelling programs in pediatric wards can mitigate these effects and foster social development. These findings are consistent with international research on the role of non-pharmacological interventions in improving social skills among children with chronic illnesses [ 36 , 37 ]. The significant improvement in self-adjustment scores suggests that storytelling may help children regulate emotions more effectively and develop adaptive coping strategies in response to the stress of hospitalization. Similar results were reported by Compas et al. [ 19 ] and Timberlake et al. [ 22 ]. As can be seen in Table 1 , storytelling intervention improved all dimensions of the child's social adjustment in this short period. In interpreting the findings, it can be stated that identification with story characters enables children to symbolically experience their own issues and learn coping strategies through narrative modeling. Story characters often encounter challenges similar to those faced by children and demonstrate methods of problem-solving, seeking support, and using social skills. By observing these behaviors, children learn to model them, which may strengthen their self-confidence and coping ability. This mechanism is consistent with Compas’s stance on the role of coping strategies in social adjustment during childhood[ 19 ]. Among the subscales, the greatest improvements were observed in assertion and cooperation, likely because storytelling provides an opportunity for children to express opinions, engage in dialogue, participate actively in story progression, and practice social roles. Responsibility also increased significantly, though to a lesser extent, perhaps due to its more gradual nature and dependence on stable behavioral patterns shaped by environmental and familial factors. The smallest improvement was seen in emotional self-control, which is understandable considering that emotion regulation typically requires prolonged practice and structured reinforcement. Therefore, integrating storytelling with other approaches—such as play therapy or cognitive-behavioral techniques—may enhance long-term outcomes and warrants exploration in future research. Based on these results, storytelling is recommended alongside medical care as a supportive psychosocial intervention in pediatric wards. Children with chronic illness often experience social withdrawal due to hospitalization, and such interventions can enhance peer interaction, family relationships, and social skill development. these findings align with international evidence demonstrating the benefits of non-pharmacological interventions in improving psychosocial outcomes among hospitalized children. Storytelling interventions have been shown to reduce anxiety and fear in hospitalized children[ 38 ] and, when combined with play-based approaches, can improve social skills including cooperation and self-expression[ 9 ]. Shi Huan Ku et al showed in their systematic review that storytelling has been associated with enhanced positive emotions and reduced stress in pediatric settings[ 38 ]. In conclusion, structured storytelling appears to be an effective and practical method for improving social adjustment in children with chronic illness, particularly in enhancing assertion, cooperation, and responsibility. Future studies are encouraged to extend the intervention duration, incorporate follow-up assessments, and examine the effects of combining storytelling with complementary therapeutic approaches. Strengths and Limitations This study has several strengths. First, it is one of the few interventions focusing specifically on children with chronic illness, a population that is often neglected in psychosocial research. The use of a structured storytelling program designed based on developmental needs allowed for consistency across sessions and ensured that children were actively engaged in the process. Another strength is the use of a standardized and psychometrically validated tool (SSRS – Shahim, 2004) to assess social skills, which enabled accurate evaluation of the sub-dimensions including cooperation, assertion, responsibility, and self-control. Additionally, the randomized allocation of participants and the presence of a control group enhanced internal validity and strengthened the causal interpretation of the observed improvements. Despite these strengths, several limitations should be acknowledged. First, the sample size was relatively small and limited to a single clinical center, which may reduce the generalizability of the findings to broader pediatric populations or to other chronic conditions. Second, the follow-up period was not included; therefore, long-term retention or sustainability of the effects remains unknown. Third, the intervention relied partly on self-report by parents, which might be influenced by subjective perception or social desirability bias. Furthermore, while the storytelling program improved social skills, emotional self-control showed smaller changes, suggesting that more intensive or combined interventions might be required to target emotional regulation effectively. Future studies are recommended to include larger multi-center samples, integrate follow-up assessments, and compare storytelling with other psychosocial interventions. Conclusion The findings of this study demonstrate that an eight-session structured storytelling program can significantly enhance social skills in children with chronic illness, particularly in the domains of assertion, cooperation, and responsibility. Although improvements in emotional self-control were smaller, the overall increase in total SSRS scores suggests that storytelling can serve as an effective, low-cost psychosocial intervention within pediatric hospital settings. By providing a safe symbolic space for emotional expression and social learning, storytelling may reduce the psychosocial burden associated with hospitalization and support healthier patterns of interaction with peers and family. Given its feasibility and positive outcomes, integrating storytelling into routine pediatric care is recommended. Future research should examine long-term follow-up effects, extend intervention duration, and evaluate combined approaches to strengthen outcomes, especially in emotional regulation. Abbreviations SPSS – Statistical Package for the Social Sciences SSRS- Social Skills Rating System CBT- Cognitive Behavioral Therapy Declarations Ethical approval and consent of participate Ethics approval and consent to participate: Approved by the Ethics Committee of Lorestan University of Medical Sciences (IR.LUMS.REC.1399.228). Written informed consent was obtained from all participants’ parents. The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all participants. Participants were assured of the confidentiality of their information, that results would be reported in aggregate form, and that they could withdraw at any time without any impact on their medical care. No adverse effects resulting from the intervention were reported by children or parents. Consent for publications Not Applicable Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request . Competing interests: The authors declare no competing interests. Funding: This study received no specific grant from any funding agency. Authors’ contributions: MA and AF contributed to data collection; KK supervised the study; RM performed data analysis; FG conceptualized the study and drafted the manuscript. All authors reviewed and approved the final version. Acknowledgments: The authors thank the participating children, their parents, and the hospital staff for their cooperation. References Davis AM, et al. Transition care for children with special health care needs. Pediatrics. 2014;134(5):900–8. Hacker K. The burden of chronic disease. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 2024. 8(1): pp. 112–119. Burns KH, et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–46. Parsons ES et al. Climate change and inequality. Pediatric research, 2024: pp. 1–8. Khanna AK, et al. 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Homai R, Kajbaf MB, Siadat SA. The effect of storytelling on children's adaptation. Psychol Stud, 2009(52): pp. 133–49. Gresham FM, Elliott S. Social skills rating system (SSRS). Minneapolis, MN,; 1990. Gresham FM, et al. Comparability of the Social Skills Rating System to the Social Skills Improvement System: Content and psychometric comparisons across elementary and secondary age levels. School Psychol Q. 2011;26(1):27. Shahim S. Standardization of Social Skills Rating System for Preschool Children. Iran J Psychiatry Clin Psychol. 2005;11(2):176–86. Dokhanchi H. Children's social adaptability scale . 1998. Mahmoudi M, Mir Zamani SM, Zabihi R. The Relationship Between Parental Mental Health and Adolescents of Elementary Schoolchildren in District 17 of Tehran. J Excellence Couns Psychother. 2018;7(27):14–22. Ajorloo M, Irani Z, Aliakbari M, Dehkordi. Story therapy effect on reducing anxiety and improvement habits sleep in children with cancer under chemotherapy. Health Psychol. 2016;5(18):87–107. Gonçalves LL, et al. Massage and storytelling reduce aggression and improve academic performance in children attending elementary school. Occup therapy Int. 2017;2017(1):5087145. Darling SJ, et al. Behavioral intervention for social challenges in children and adolescents: a systematic review and meta-analysis. JAMA Pediatr. 2021;175(12):e213982–213982. Gjærde LK, et al. Play interventions for paediatric patients in hospital: a scoping review. BMJ open. 2021;11(7):e051957. Ku SH, Chua JS, Shorey S. Effect of storytelling on anxiety and fear in children during hospitalization: A systematic review and meta-analysis. J Pediatr Nurs. 2025;80:41–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Jan, 2026 Reviewers agreed at journal 26 Jan, 2026 Reviews received at journal 23 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers invited by journal 12 Jan, 2026 Editor invited by journal 02 Jan, 2026 Editor assigned by journal 02 Jan, 2026 Submission checks completed at journal 27 Dec, 2025 First submitted to journal 27 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8104834","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":573652647,"identity":"a94ed64e-22a1-48f9-942b-aea628dcfea5","order_by":0,"name":"Maryam Abadar","email":"","orcid":"","institution":"Lorestan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"","lastName":"Abadar","suffix":""},{"id":573652652,"identity":"422aaac4-56f8-4177-8198-1d473970bf08","order_by":1,"name":"Afsaneh Beiranvand","email":"","orcid":"","institution":"Lorestan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Afsaneh","middleName":"","lastName":"Beiranvand","suffix":""},{"id":573652654,"identity":"96951dea-b9c8-4fdf-a973-9de244c7847c","order_by":2,"name":"Seyedeh Fatemeh Ghasemi","email":"","orcid":"","institution":"Lorestan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyedeh","middleName":"Fatemeh","lastName":"Ghasemi","suffix":""},{"id":573652661,"identity":"b183846b-65e9-4aaf-8d4f-4f9fa134b172","order_by":3,"name":"Rasool Mohammadi","email":"","orcid":"","institution":"Lorestan University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Rasool","middleName":"","lastName":"Mohammadi","suffix":""},{"id":573652662,"identity":"83d17355-a260-4412-8036-0e038ea2ce3b","order_by":4,"name":"Kimia Karami","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACCQk2MM3DDyITCkjRItkA0mJAghYGgwNgkggtkrPbEj9X1GyTMT6/OvHDAwMGeX6xA/i1SMscOyx55thtHrMbbzdLAB1mOHN2An4tchLpDZINbCAtZzeAtCQY3Caspflnw7/bPMYzzm7+QZQWaYm0Y5KNbbd5DPh7txFni+ScY2mWjX23eSRu8G6zSDCQIOwXidttxjcbvt225+8/u/nmjwobeX5pAlqQNINVShCrHAT4D5CiehSMglEwCkYSAAAmPkP2h/f1JwAAAABJRU5ErkJggg==","orcid":"","institution":"Lorestan University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Kimia","middleName":"","lastName":"Karami","suffix":""}],"badges":[],"createdAt":"2025-11-13 10:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8104834/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8104834/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100407034,"identity":"1196ebcc-ff7e-4361-be42-a1bc6c2cc0dd","added_by":"auto","created_at":"2026-01-16 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13:04:23","extension":"xml","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":113119,"visible":true,"origin":"","legend":"","description":"","filename":"7f1716c3e50f4035a3c6071acf69ff431structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8104834/v1/f0e74a25fd6f8d6e86f9b966.xml"},{"id":100407380,"identity":"e9e978c6-6b7e-48e6-8021-47ce31670957","added_by":"auto","created_at":"2026-01-16 13:04:26","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127660,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8104834/v1/eda785abdce7d3218aa7342d.html"},{"id":100407360,"identity":"36ae72fa-5775-42f8-a960-a98816af2221","added_by":"auto","created_at":"2026-01-16 13:04:23","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":63863,"visible":true,"origin":"","legend":"\u003cp\u003eThe CONSORT diagram.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8104834/v1/113694f14b3b481b36691bcf.jpg"},{"id":100546293,"identity":"dfbbe293-f405-480c-ac7a-cf78841e2eb3","added_by":"auto","created_at":"2026-01-19 08:05:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1147915,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8104834/v1/4ddaf944-ae8b-4b0e-91d6-174700c7d835.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Structured Storytelling on Social Skills and Social Adaptation in Hospitalized Children with Chronic Illnesses: A Quasi-Experimental Study ","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOver recent decades, a notable shift has occurred in pediatric health trends, marked by a substantial rise in the prevalence of chronic diseases among children and adolescents[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Whereas infectious conditions once dominated the burden of disease in this population, chronic diseases now account for a significant portion of long-term health concerns[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinically, chronic diseases are commonly defined as a condition that persists for at least three months annually and requires continuous medical management or restricts a child\u0026rsquo;s everyday functioning[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Disorders such as anemia, cerebral palsy, thalassemia, epilepsy, diabetes, chronic respiratory conditions, hemophilia, neuromuscular diseases, and childhood cancers represent some of the most frequent chronic conditions in this age group[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Chronic illnesses can disrupt normative developmental trajectories and interfere with children\u0026rsquo;s ability to participate fully in social contexts, leading to difficulties in social competence and interpersonal functioning [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSocial skills refer to the set of learned behaviors that enable individuals to interact effectively with others in a variety of social contexts; these include cooperation, assertion, self-control, empathy, and communication[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Children who lack adaptive social skills often experience peer rejection, social withdrawal, or maladaptive social responses, which can undermine their psychosocial functioning and overall well-being[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Difficulties in social competence and adjustment may manifest as poor interaction with peers, reduced participation in group activities, and challenges in communicating needs and emotions effectively [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Such challenges not only affect children\u0026rsquo;s current functioning but can also persist into adolescence and adulthood, influencing academic engagement, community participation, and quality of life [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the foundational role of social skills in adaptive functioning, early identification and intervention targeting these competencies are crucial. Interventions that enhance social skills can reduce problematic behaviors, improve peer relations, and strengthen adaptive responses in social contexts[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Mental health holds equal importance to physical health in childhood[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], yet these children frequently face additional burdens due to repeated hospitalizations, which may further contribute to emotional and behavioral disturbances[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHospitalization itself can be a distressing experience for children. The unfamiliar environment, separation from caregivers, and concerns related to illness often provoke anxiety, sadness, fear, and withdrawal, all of which can impede healthy social development[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Social development constitutes a fundamental process through which children learn to interact, form meaningful relationships, and regulate their behavior. This developmental domain includes peer and adult interactions, comprehension of social norms, and acquisition of critical skills such as empathy, cooperation, and effective communication[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOn the other hand, chronic childhood diseases elevate the risk of emotional and behavioral difficulties, which may manifest as poor treatment adherence, maladaptive social behaviors, and reduced social competence[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Consequently, early interventions that specifically address maladaptive behaviors can substantially enhance children\u0026rsquo;s emotional, behavioral, and social outcomes[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile pharmacological treatments address the physical dimensions of chronic illness, non-pharmacological interventions aimed at enhancing social and emotional functioning have gained attention for their potential to improve psychosocial outcomes[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Common approaches to enhancing social competencies in children include structured social skills training, cooperative play interventions, role-plays, and reciprocal dialogue activities[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Among emerging strategies, storytelling therapy or narrative-based interventions offers a simple, low-cost option that can be implemented even by nurses in pediatric wards[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. For example, the study conducted by Nuray Macuncu and Melahat Akgun Kostak (2025) showed that incorporating storytelling and drawing during inhalation therapy helped reduce children\u0026rsquo;s fear and negative emotions and increased parental satisfaction compared with standard routines[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Similarly, research by Yousefi and colleagues on 330 hospitalized children with leukemia demonstrated that storytelling significantly alleviated their pain levels [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong emerging strategies, storytelling therapy or narrative-based interventions offers a creative, child-friendly, and low-cost option that can be implemented in clinical and educational settings to facilitate social learning[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Storytelling engages children in reflective thinking, encourages perspective taking, and provides opportunities for rehearsal of social responses in safe, vicarious contexts[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Such findings underscore the promise of structured storytelling in fostering core social competencies. Although existing evidence highlights the potential benefits of storytelling for children\u0026rsquo;s development, a considerable gap remains regarding its specific effects on social skills and social adjustment among children with chronic illnesses, especially in clinical or hospital settings[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Current literature indicates that intervention studies focused on enhancing social competencies in this population are limited, despite the clear importance of these outcomes. Considering the continued high prevalence of chronic diseases among children \u0026mdash; who represent a vital societal resource \u0026mdash; greater attention to psychological and non-pharmacological interventions targeting social adaptation and competence is warranted[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. School-age children (6\u0026ndash;10 years) are naturally inquisitive, exploratory, and learn much of their social competencies through interaction and narrative engagement, making structured storytelling an appealing and developmentally appropriate intervention for this group[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccordingly, the present study was designed to examine the impact of structured storytelling intervention on social skills and social adjustment among hospitalized children aged 6 to 10 years with chronic diseases.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eThis study was conducted between 2020 and 2022, as a quasi-experimental interventional study involving 60 hospitalized children aged 6 to 10 years in the pediatric departments of the educational\u0026ndash;medical centers of Behbahan, Khuzestan, Iran.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSample Size Determination\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated based on the findings of Homai et al. (2015) [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Considering a significance level of α\u0026thinsp;=\u0026thinsp;0.05, a statistical power of 90%, and the reported means and standard deviations of social adaptation scores in the intervention and control groups (17.54\u0026thinsp;\u0026plusmn;\u0026thinsp;3.81 and 13.54\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57, respectively), the required sample size for each group was estimated as 17 participants using the formula for comparing two means. Accounting for a potential attrition rate of 20%, the final sample size was increased to 30 participants per group, using the following formula:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\frac{({z}_{1-\\frac{a}{2}}+{z}_{1-\\beta\\:}{)}^{2}({\\delta\\:}_{1}^{2}+{\\delta\\:}_{2}^{2})}{({\\mu\\:}_{1}-{\\mu\\:}_{2}{)}^{2}}$$\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equb\" name=\"EquationSource\"\u003e\n$$\\:\\frac{(1.96+0.84{)}^{2}({3.81}_{}^{2}+{13/54}_{}^{2})}{(17.54+13/54{)}^{2}}=30$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eInclusion and Exclusion Criteria\u003c/h3\u003e\n\u003cp\u003eInclusion criteria consisted of: children aged 6\u0026ndash;10 years (school age); a confirmed diagnosis of at least one chronic illness (e.g., hemophilia, anemia, cancer, epilepsy and seizures, cardiovascular diseases, chronic respiratory infections, or diabetes); obtaining verbal and written informed consent from parents; willingness of both parents and the child to continue participation throughout the study; and living with both biological parents.\u003c/p\u003e \u003cp\u003eExclusion criteria included: withdrawal or unwillingness of the child or parents at any stage; discharge before completion of the intervention sessions; voluntary early discharge; development of a new acute illness; exacerbation of the underlying disease; or the child's death during the study period (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eSampling and Randomization\u003c/h3\u003e\n\u003cp\u003eSampling was performed using a convenience approach among eligible hospitalized children (conducted by the first author). Randomization followed a permuted block method using 15 four-person blocks to ensure balanced allocation across groups. Within each block, all six possible permutations of assigning two participants to the intervention group (A) and two to the control group (B) were generated: AABB, ABAB, ABBA, BBAA, BABA, and BAAB.\u003c/p\u003e \u003cp\u003eThese block sequences were placed into sealed envelopes by the second author\u0026mdash;who remained blinded to the allocation\u0026mdash;and then provided to the first author. Each time a participant entered the study, one envelope was randomly selected (with replacement), and children were assigned to their respective groups based on the sequence indicated. Enrollment continued until the target sample size was achieved. In this study, both the participants and the interventionist (first author) were aware of group assignments, whereas the biostatistician remained blinded.\u003c/p\u003e\n\u003ch3\u003eData Collection Instruments\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDemographic Questionnaire\u003c/h2\u003e \u003cp\u003eA demographic information form was used to collect background characteristics of participants, including the child\u0026rsquo;s gender, mode of delivery, mother\u0026rsquo;s educational level, birth order, type of chronic disease, family history of genetic disorders, maternal age at childbirth, child\u0026rsquo;s chronological age, and duration of hospitalization. The face validity of the form was assessed by ten nursing faculty members and confirmed based on clarity and relevance of items.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSocial Skills Rating System (SSRS)\u003c/h3\u003e\n\u003cp\u003eSocial skills were assessed using the Social Skills Rating System (SSRS) developed by Gresham and Elliott (1990), a norm-referenced instrument designed to evaluate social behaviors and problem behaviors among preschool and school-aged children[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The SSRS includes three parallel forms (parent, teacher, and student), of which the parent form was used in this study. The parent form contains 34\u0026ndash;57 items scored on a 3-point Likert scale (0\u0026thinsp;=\u0026thinsp;never, 1\u0026thinsp;=\u0026thinsp;sometimes, 2\u0026thinsp;=\u0026thinsp;very often), measuring five subscales: cooperation, assertion, responsibility, empathy, and self-control[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Subscale scores are summed to generate standardized scores and percentile ranks based on normative samples. The SSRS has demonstrated strong psychometric properties, with internal consistency reported at α\u0026thinsp;=\u0026thinsp;0.90 for the Social Skills scale, and test\u0026ndash;retest reliability of 0.80 for parent ratings in elementary-aged children. The Persian version of SSRS has been translated, culturally adapted, and validated in Iranian children, showing acceptable reliability with Cronbach\u0026rsquo;s alpha of α\u0026thinsp;=\u0026thinsp;0.87, indicating good internal consistency. The version standardized for Iranian preschool children by Shahim (2005) demonstrated satisfactory construct validity and has been recommended for evaluating cooperation, assertion, self-control, and responsibility[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the present study, the questionnaire was completed as a parent-report form by one of the caregivers.\u003c/p\u003e\n\u003ch3\u003eChildren’s Social Adaptation Scale\u003c/h3\u003e\n\u003cp\u003eThe Children's Social Adaptation Scale, developed by Dokhanchi (1998), assesses social adaptation through 37 four-point Likert items (never, rarely, sometimes, often), completed by parents (typically the mother) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Adaptation-related items are scored from 0 (never) to 3 (often), while maladaptive items are reverse-scored. Total scores range from 0 to 111 and are categorized into five levels: very low (\u0026lt;\u0026thinsp;52), low (52\u0026ndash;65), moderate (65\u0026ndash;77), high (77\u0026ndash;90), and very high (\u0026gt;\u0026thinsp;90). Reliability reported for this scale includes split-half and Cronbach\u0026rsquo;s alpha coefficients of 0.79 and 0.72, respectively, and a criterion validity of 0.81. Mahmoudi et al. reported a Cronbach\u0026rsquo;s alpha of 0.81, indicating acceptable internal consistency [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntervention\u003c/h2\u003e \u003cp\u003eIn this study, participants in the intervention group, in addition to receiving routine/standard pediatric care, participated in an eight-session storytelling therapy program. The intervention was delivered over four consecutive days, with two 45-minute sessions per day, conducted by the primary researcher, who had previously completed specialized training in storytelling and obtained certified accreditation from authorized institutions. The content of the stories was selected and standardized with the approval of storytelling instructors and experts from the Children\u0026rsquo;s Intellectual Development Center. Sessions were held in the afternoon and evening, coordinated with ward staff and following renewed informed consent from both parents and children. During each session, the researcher actively engaged children using professional storytelling techniques, including the use of puppets, drawing, body language, changes in tone and voice, strategic pauses (suspense), and predictive questioning to anticipate story developments. These strategies aimed to enhance attention, problem-solving skills, and social competence.The control group received only standard hospital care without additional educational or story-based interventions.\u003c/p\u003e \u003cp\u003eThe stories were drawn from reputable sources, including \u003cem\u003e\u0026ldquo;Ay Ghesseh Ghesseh Ghesseh\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;Storytelling\u0026rdquo;\u003c/em\u003e by Dr. Arthur Roshan (e.g., \u003cem\u003e\u0026ldquo;When Everyone Gets There\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;Fingiliha\u0026rdquo;\u003c/em\u003e), which had previously been shown to reduce anxiety in children. Additionally, stories by notable Iranian authors such as Mostafa Rahman Doost, Farhad Hassanzadeh, Sarvar Pouria (scientific stories), Sosan Taqdis, Mehdi Mirkiani, and collections such as \u003cem\u003e\u0026ldquo;365 Stories\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;My Hero is You\u0026rdquo;\u003c/em\u003e were included. Story selection was age-appropriate, with narratives that were realistic, concise, and featured a clear plot. Story protagonists typically faced challenges or limitations (similar but not identical to the child\u0026rsquo;s condition) and resolved problems by leveraging personal abilities, family support, and social skills. The purpose was to foster children\u0026rsquo;s self-confidence, problem-solving abilities, emotional regulation, and social competence.\u003c/p\u003e \u003cp\u003eThe storytelling content included themes such as improving quality of life during hospitalization, practicing self-care behaviors (e.g., recognizing when to use inhalers), and developing skills related to the child\u0026rsquo;s healthy roles (such as engaging in structured activities). Additionally, the stories incorporated health-promoting skills, coping and compensation strategies, narratives of heroes with physical conditions, and messages emphasizing that illness is not the child\u0026rsquo;s fault, that strength comes from within, and that children with chronic illnesses are no different from healthy peers in their ability to pursue their goals.\u003c/p\u003e \u003cp\u003eQuestionnaires were administered on the first day of hospitalization and again on the tenth day. Parents completed demographic forms and the Social Development and Children\u0026rsquo;s Social Adaptation Scales before the intervention, and post-intervention assessments were also completed by parents in both groups. Data collection was conducted exclusively by the lead researcher, with no involvement from other authors. Participants were given 20\u0026ndash;30 minutes to complete the instruments independently, after which the researcher reviewed all responses for completeness and prompted participants to address any missing items. No participant dropout or missing data occurred during the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics, including mean, standard deviation, frequency, and percentage, were used to summarize data. The Shapiro\u0026ndash;Wilk test assessed normality assumptions. For between-group comparisons, the chi-square test and Fisher\u0026rsquo;s exact test were applied to categorical variables, while independent t-tests were used for continuous variables. Given normal data distribution, independent t-tests were employed to compare group means. All analyses were conducted using SPSS version 25, with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe demographic characteristics of participants were comparable across the intervention and control groups. In both groups, the majority of children were male (66.7% in the intervention group vs. 60% in the control group). Mode of delivery was similar, with approximately half of the children in each group born via vaginal delivery. Regarding maternal education, the largest proportion in both groups had a high school diploma or lower (56.7% in the intervention group vs. 50% in the control group). Birth order distribution was also comparable, with 86.7% of children in both groups having a birth order of two or lower. The presence of a family history of genetic conditions was nearly identical across groups.\u003c/p\u003e \u003cp\u003eIn terms of chronic illness type, cystic fibrosis and asthma were the most prevalent in both groups, and the overall distribution of disease types did not differ significantly between groups. No statistically significant differences were observed between the intervention and control groups for any demographic or clinical variables (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating baseline homogeneity between groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of participants (n\u0026thinsp;=\u0026thinsp;60).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.789\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMode of Delivery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCesarean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or lower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.606\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate degree or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth Order\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (86.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (13.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGenetic History\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (56.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (43.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChronic Diseases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCystic Fibrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.718\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (23.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEpilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (23.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Fisher\u0026rsquo;s exact test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePrior to the intervention, no significant differences were observed between the groups regarding the mean scores of self-adaptions, family adjustment, and peer adjustment (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, following the intervention, children in the intervention group demonstrated significantly higher scores across all domains of social adaption compared with the control group.\u003c/p\u003e \u003cp\u003eThe mean score of self-adaptions increased significantly in the intervention group compared with the control group after the intervention (P\u0026thinsp;=\u0026thinsp;0.001). Similarly, family adaption scores showed a significant post-intervention improvement in the intervention group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although pre-intervention peer-adjustment scores were comparable between the two groups, a significant improvement was observed in the intervention group following the storytelling program (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Overall, the storytelling intervention led to meaningful enhancements in all dimensions of social adjustment (self, family, peers) among children in the intervention group compared with controls (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean scores of social adaptions and its dimensions before and after the intervention in the intervention and control groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCoping with Self (Before)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.50 (3.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.416\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.23 (3.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCoping with Self (After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.10 (3.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.33 (3.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDifference (Before\u0026ndash;After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.60 (2.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.10 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCoping with Family (Before)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.20 (3.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.57 (2.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCoping with Family (After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.20 (2.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.03 (2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDifference (Before\u0026ndash;After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.00 (2.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.47 (1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCoping with Peers (Before)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.20 (3.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.03 (3.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCoping with Peers (After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.55 (2.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.46 (3.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDifference (Before\u0026ndash;After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.33 (2.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.43 (1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTotal Social adaption (Difference Before\u0026ndash;After)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.37 (5.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.00 (2.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Independent samples t test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe total SSRS score increased significantly in the intervention group compared to the control group (Mean difference\u0026thinsp;=\u0026thinsp;+\u0026thinsp;13.50, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Analysis of the SSRS subscales revealed that structured storytelling had the greatest effect on assertion and cooperation, a moderate effect on responsibility, and the smallest improvement in self-control, although still statistically significant (p\u0026thinsp;=\u0026thinsp;0.041). No significant changes were observed in the control group across any domains. These findings indicate that the eight-session storytelling program effectively enhanced multiple components of social skills in children with chronic illness\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean scores of Total Social Skills Score (SSRS) before and after the intervention in the intervention and control groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD Before\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD After\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Diff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e*P-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTotal Social Skills Score (SSRS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e43.10\u0026thinsp;\u0026plusmn;\u0026thinsp;5.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e44.20\u0026thinsp;\u0026plusmn;\u0026thinsp;6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e42.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e55.80\u0026thinsp;\u0026plusmn;\u0026thinsp;5.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;13.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Independent samples t test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAfter the intervention, the total social skills score increased significantly in the intervention group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while no noticeable change was observed in the control group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean scores of SSRS Subscales before and after the intervention in the intervention and control groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003cp\u003eBefor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003cp\u003eAfter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean Diff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eAssertion (Self-expression)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.80\u0026thinsp;\u0026plusmn;\u0026thinsp;2.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e15.60\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;4.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e11.10\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e11.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCooperation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e11.50\u0026thinsp;\u0026plusmn;\u0026thinsp;2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e15.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;3.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e11.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e11.90\u0026thinsp;\u0026plusmn;\u0026thinsp;3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eResponsibility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e9.90\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e12.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e10.60\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSelf-control (Emotional regulation Control\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e) 11.30\u0026thinsp;\u0026plusmn;\u0026thinsp;2.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e10.70\u0026thinsp;\u0026plusmn;\u0026thinsp;2.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e+\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Independent samples t test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eFollowing the intervention, the total SSRS score increased significantly in the intervention group compared to the control group (Mean difference\u0026thinsp;=\u0026thinsp;+\u0026thinsp;13.50, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Analysis of the SSRS subscales revealed that structured storytelling had the greatest effect on assertion and cooperation, a moderate effect on responsibility, and the smallest improvement in self-control, although still statistically significant (p\u0026thinsp;=\u0026thinsp;0.041). No significant changes were observed in the control group across any domains. These findings indicate that the eight-session storytelling program effectively enhanced multiple components of social skills in children with chronic illness.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ehis study aimed to evaluate the impact of storytelling therapy on the social development and social adaptation of children living with chronic diseases. The findings of the present study demonstrated that implementing a storytelling therapy program resulted in significant improvements across all dimensions of social adaptation\u0026mdash;including self-adjustment, family adjustment, and peer adjustment\u0026mdash;as well as enhanced social development among hospitalized children with chronic illnesses. While no significant differences existed between the groups before the intervention, the eight-session storytelling program produced notable post-intervention improvements in the intervention group compared with the control group. Among the chronic conditions, hypothyroidism, asthma, epilepsy, and cystic fibrosis were the most prevalent in both groups. These results underscore the positive impact of storytelling as a low-cost, psychosocial intervention that is feasible for hospital settings.\u003c/p\u003e \u003cp\u003eThe present findings are consistent with previous study. Ajorloo et al. reported that storytelling reduced anxiety and improved sleep habits among children with cancer undergoing chemotherapy [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Similarly, Gon\u0026ccedil;alves et al. found that both massage and storytelling were effective strategies for reducing aggression by enhancing shared experiences and social interaction; children exposed to stories identified with characters and achieved higher levels of social adaptation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Homai et al., in a study of 40 children aged 4 to 6 years, also demonstrated that storytelling-based instruction improved behavioral adjustment and emotional regulation, suggesting that greater adjustment enhances the capacity for self-regulation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Hakim et al. (2008) similarly reported reductions in anxiety and increased psychological safety among hospitalized children exposed to storytelling [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, Timberlake (2000) and Timberlake et al. (2023) have shown the efficacy of story-based and cognitive\u0026ndash;behavioral interventions in improving social skills, emotional regulation, and reducing maladaptive behaviors [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The consistency across studies likely stems from the engaging, interactive, and non-threatening nature of storytelling, which encourages active participation and facilitates social learning.\u003c/p\u003e \u003cp\u003eStorytelling provides a symbolic and safe environment that allows children to indirectly process personal and social challenges. Story characters often encounter difficulties similar to those faced by the child, and overcome them through social skills, family support, and problem-solving. Identifying with such characters enhances self-confidence, emotional understanding, and adoption of appropriate behavioral patterns. This aligns with findings by Compas et al. (2012), who emphasized that coping strategies learned in childhood play a major role in subsequent social and psychological adjustment [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe results further indicate that storytelling not only improves individual adjustment but also enhances interactions with family members and peers (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Since prolonged hospitalization restricts peer interaction and may lead to social isolation, implementing storytelling programs in pediatric wards can mitigate these effects and foster social development. These findings are consistent with international research on the role of non-pharmacological interventions in improving social skills among children with chronic illnesses [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe significant improvement in self-adjustment scores suggests that storytelling may help children regulate emotions more effectively and develop adaptive coping strategies in response to the stress of hospitalization. Similar results were reported by Compas et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Timberlake et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. As can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, storytelling intervention improved all dimensions of the child's social adjustment in this short period.\u003c/p\u003e \u003cp\u003eIn interpreting the findings, it can be stated that identification with story characters enables children to symbolically experience their own issues and learn coping strategies through narrative modeling. Story characters often encounter challenges similar to those faced by children and demonstrate methods of problem-solving, seeking support, and using social skills. By observing these behaviors, children learn to model them, which may strengthen their self-confidence and coping ability. This mechanism is consistent with Compas\u0026rsquo;s stance on the role of coping strategies in social adjustment during childhood[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the subscales, the greatest improvements were observed in assertion and cooperation, likely because storytelling provides an opportunity for children to express opinions, engage in dialogue, participate actively in story progression, and practice social roles. Responsibility also increased significantly, though to a lesser extent, perhaps due to its more gradual nature and dependence on stable behavioral patterns shaped by environmental and familial factors. The smallest improvement was seen in emotional self-control, which is understandable considering that emotion regulation typically requires prolonged practice and structured reinforcement. Therefore, integrating storytelling with other approaches\u0026mdash;such as play therapy or cognitive-behavioral techniques\u0026mdash;may enhance long-term outcomes and warrants exploration in future research.\u003c/p\u003e \u003cp\u003eBased on these results, storytelling is recommended alongside medical care as a supportive psychosocial intervention in pediatric wards. Children with chronic illness often experience social withdrawal due to hospitalization, and such interventions can enhance peer interaction, family relationships, and social skill development. these findings align with international evidence demonstrating the benefits of non-pharmacological interventions in improving psychosocial outcomes among hospitalized children. Storytelling interventions have been shown to reduce anxiety and fear in hospitalized children[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and, when combined with play-based approaches, can improve social skills including cooperation and self-expression[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Shi Huan Ku et al showed in their systematic review that storytelling has been associated with enhanced positive emotions and reduced stress in pediatric settings[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn conclusion, structured storytelling appears to be an effective and practical method for improving social adjustment in children with chronic illness, particularly in enhancing assertion, cooperation, and responsibility. Future studies are encouraged to extend the intervention duration, incorporate follow-up assessments, and examine the effects of combining storytelling with complementary therapeutic approaches.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths. First, it is one of the few interventions focusing specifically on children with chronic illness, a population that is often neglected in psychosocial research. The use of a structured storytelling program designed based on developmental needs allowed for consistency across sessions and ensured that children were actively engaged in the process. Another strength is the use of a standardized and psychometrically validated tool (SSRS \u0026ndash; Shahim, 2004) to assess social skills, which enabled accurate evaluation of the sub-dimensions including cooperation, assertion, responsibility, and self-control. Additionally, the randomized allocation of participants and the presence of a control group enhanced internal validity and strengthened the causal interpretation of the observed improvements.\u003c/p\u003e \u003cp\u003eDespite these strengths, several limitations should be acknowledged. First, the sample size was relatively small and limited to a single clinical center, which may reduce the generalizability of the findings to broader pediatric populations or to other chronic conditions. Second, the follow-up period was not included; therefore, long-term retention or sustainability of the effects remains unknown. Third, the intervention relied partly on self-report by parents, which might be influenced by subjective perception or social desirability bias. Furthermore, while the storytelling program improved social skills, emotional self-control showed smaller changes, suggesting that more intensive or combined interventions might be required to target emotional regulation effectively.\u003c/p\u003e \u003cp\u003eFuture studies are recommended to include larger multi-center samples, integrate follow-up assessments, and compare storytelling with other psychosocial interventions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this study demonstrate that an eight-session structured storytelling program can significantly enhance social skills in children with chronic illness, particularly in the domains of assertion, cooperation, and responsibility. Although improvements in emotional self-control were smaller, the overall increase in total SSRS scores suggests that storytelling can serve as an effective, low-cost psychosocial intervention within pediatric hospital settings. By providing a safe symbolic space for emotional expression and social learning, storytelling may reduce the psychosocial burden associated with hospitalization and support healthier patterns of interaction with peers and family. Given its feasibility and positive outcomes, integrating storytelling into routine pediatric care is recommended. Future research should examine long-term follow-up effects, extend intervention duration, and evaluate combined approaches to strengthen outcomes, especially in emotional regulation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSPSS – Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eSSRS- Social Skills Rating System\u003c/p\u003e\n\u003cp\u003eCBT- Cognitive Behavioral Therapy\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent of participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate: Approved by the Ethics Committee of Lorestan University of Medical Sciences (IR.LUMS.REC.1399.228). Written informed consent was obtained from all participants\u0026rsquo; parents.\u0026nbsp;The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all participants.\u0026nbsp;Participants were assured of the confidentiality of their information, that results would be reported in aggregate form, and that they could withdraw at any time without any impact on their medical care. No adverse effects resulting from the intervention were reported by children or parents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This study received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e MA and AF contributed to data collection; KK supervised the study; RM performed data analysis; FG conceptualized the study and drafted the manuscript. All authors reviewed and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e The authors thank the participating children, their parents, and the hospital staff for their cooperation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDavis AM, et al. Transition care for children with special health care needs. Pediatrics. 2014;134(5):900\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHacker K. \u003cem\u003eThe burden of chronic disease.\u003c/em\u003e Mayo Clinic Proceedings: Innovations, Quality \u0026amp; Outcomes, 2024. 8(1): pp. 112\u0026ndash;119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurns KH, et al. Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParsons ES et al. \u003cem\u003eClimate change and inequality.\u003c/em\u003e Pediatric research, 2024: pp. 1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhanna AK, et al. Social, psychological and financial burden on caregivers of children with chronic illness: a cross-sectional study. Indian J Pediatr. 2015;82:1006\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaberi M, Fani L, Saberi. Components of chronic illness in the elderly: a review study. Clin Excellence. 2021;11(1):54\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrady AM, Deighton J, Stansfeld S. Chronic illness in childhood and early adolescence: A longitudinal exploration of co-occurring mental illness. Dev Psychopathol. 2021;33(3):885\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsghari F, Akhavan M, GHASEMI JR. \u003cem\u003eEffect of storytelling method on social skills in children with Down syndrome.\u003c/em\u003e 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmel AK, Rahnamaei H, Hashemi Z. Play therapy and storytelling intervention on children's social skills with attention deficit-hyperactivity disorder. J Educ health promotion, 2023(1): p. 317.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAksoy P, Baran G. The effect of story telling-based and play-based social skills training on social skills of kindergarten children: An experimental study. Educ Sci. 2020;45(204):157\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeliner B, Latal B, Spirig R. When children with profound multiple disabilities are hospitalized: A cross-sectional survey of parental burden of care, quality of life of parents and their hospitalized children, and satisfaction with family‐centered care. J Spec Pediatr Nurs. 2016;21(3):147\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilbert R, Harron K, Dearden L. \u003cem\u003eBenefits of, and barriers to, reactivating dormant trials.\u003c/em\u003e BMJ (Clinical research ed), 2015. 351: p. h5298-.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLauriola M, et al. Intolerance of uncertainty and anxiety-related dispositions predict pain during upper endoscopy. Front Psychol. 2019;10:1112.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColizzi M, Lasalvia A, Ruggeri M. Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? Int J mental health Syst. 2020;14(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFord T, et al. Data resource profile: mental health of children and young people (MHCYP) surveys. Int J Epidemiol. 2020;49(2):363\u0026ndash;g364.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHakim A et al. \u003cem\u003eImpact of storytelling on anxiety in 4\u0026ndash;7 year old children in hospital: a randomized clinical trial study.\u003c/em\u003e Scientific Journal of Hamadan Nursing \u0026amp; Midwifery Faculty-ISSN, 2008. 2008: p. 2819.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheikhzakaryaee N, et al. Effect of painting on the anxiety of hospitalized cancer children. Payesh (Health Monitor). 2016;15(1):63\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchaffer HR. Social development. Blackwell Publishing; 1996.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCompas BE, et al. Coping with chronic illness in childhood and adolescence. Ann Rev Clin Psychol. 2012;8(1):455\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFulton E, et al. Reducing maladaptive behaviors in preschool-aged children with autism spectrum disorder using the Early Start Denver Model. Front Pead. 2014;2:40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang W, Chen K, Zhang H. Effectiveness of trauma-focused cognitive behavioral therapy among maltreated children: A meta-analysis. Res social work Pract. 2023;33(8):913\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimberlake TL. A comprehensive approach to social skills training with urban African-American adolescents. Temple University; 2000.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAksoy P. The challenging behaviors faced by the preschool teachers in their classrooms, and the strategies and discipline approaches used against these behaviors: The sample of United States. Participatory Educational Res. 2020;7(3):79\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacuncu N, Kostak MA. The effect of storytelling and painting on children's fear level and parental health care satisfaction in children aged 3\u0026ndash;6 years administered inhaler medication: Randomized controlled study. J Pediatr Nurs. 2025;83:55\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuosef Pur N, Agha AR, Yousefi. The Effect of Storytelling in Pain Reduction of Children with Leucemai. Health Psychol. 2015;3(9):82\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePekdogan S. Investigation of the Effect of Story-Based Social Skills Training Program on the Social Skill Development of 5\u0026ndash;6 Year-Old Children. Online Submiss. 2016;41(183):305\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWolstencroft J, et al. A systematic review of group social skills interventions, and meta-analysis of outcomes, for children with high functioning ASD. J Autism Dev Disord. 2018;48(7):2293\u0026ndash;307.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHomai R, Kajbaf MB, Siadat SA. The effect of storytelling on children's adaptation. Psychol Stud, 2009(52): pp. 133\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGresham FM, Elliott S. Social skills rating system (SSRS). Minneapolis, MN,; 1990.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGresham FM, et al. Comparability of the Social Skills Rating System to the Social Skills Improvement System: Content and psychometric comparisons across elementary and secondary age levels. School Psychol Q. 2011;26(1):27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahim S. Standardization of Social Skills Rating System for Preschool Children. Iran J Psychiatry Clin Psychol. 2005;11(2):176\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDokhanchi H. \u003cem\u003eChildren's social adaptability scale\u003c/em\u003e. 1998.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmoudi M, Mir Zamani SM, Zabihi R. The Relationship Between Parental Mental Health and Adolescents of Elementary Schoolchildren in District 17 of Tehran. J Excellence Couns Psychother. 2018;7(27):14\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjorloo M, Irani Z, Aliakbari M, Dehkordi. Story therapy effect on reducing anxiety and improvement habits sleep in children with cancer under chemotherapy. Health Psychol. 2016;5(18):87\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGon\u0026ccedil;alves LL, et al. Massage and storytelling reduce aggression and improve academic performance in children attending elementary school. Occup therapy Int. 2017;2017(1):5087145.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDarling SJ, et al. Behavioral intervention for social challenges in children and adolescents: a systematic review and meta-analysis. JAMA Pediatr. 2021;175(12):e213982\u0026ndash;213982.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGj\u0026aelig;rde LK, et al. Play interventions for paediatric patients in hospital: a scoping review. BMJ open. 2021;11(7):e051957.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKu SH, Chua JS, Shorey S. Effect of storytelling on anxiety and fear in children during hospitalization: A systematic review and meta-analysis. J Pediatr Nurs. 2025;80:41\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"student in pediatrics nursing. Student Research Committee, School of Nursing and Midwifery, Lorestan University of Medical Sciences, Khorramabad, Iran. [email protected]","lastPublishedDoi":"10.21203/rs.3.rs-8104834/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8104834/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildren with chronic illness frequently experience challenges in social adaptation due to prolonged hospitalization, pain, and reduced opportunities for peer interaction. Storytelling has been introduced as a psychosocial intervention that may enhance social skills through emotional engagement, modeling, and symbolic problem-solving. The present study aimed to evaluate the effectiveness of a structured storytelling program on improving social skills in hospitalized children with chronic disease.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis quasi-experimental study included 60 hospitalized children with chronic illness aged 6\u0026ndash;10 years in Behbahan, Khuzestan, Iran. Participants were randomly assigned to the intervention (n\u0026thinsp;=\u0026thinsp;30) or control (n\u0026thinsp;=\u0026thinsp;30) group. The intervention group received eight 45-minute storytelling sessions over four consecutive days alongside routine care; the control group received routine care only. Social skills were assessed using the Social Skills Rating System (SSRS) and social adaptation by Dokhanchi\u0026rsquo;s Child Social Adaptation Scale before and after the intervention. Data were analyzed using appropriate statistical tests to compare total and subscale scores between groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePost-intervention, the storytelling group demonstrated significant improvements in self-adaptation (p\u0026thinsp;=\u0026thinsp;0.001), family adaptation and peer adaptation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared with controls. The total SSRS score increased significantly in the intervention group compared to the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Subscale analysis revealed the greatest improvements in assertion and cooperation, followed by responsibility, while self-control showed the smallest but still significant increase (p\u0026thinsp;=\u0026thinsp;0.041). No significant changes were observed in the control group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eStructured storytelling is a low-cost, non-pharmacological, culturally appropriate intervention that enhances social adaptation and social skills particularly assertion, cooperation, and responsibility among hospitalized children with chronic illnesses. Integrating storytelling into pediatric care may reduce psychosocial burdens and support social growth. Longer-term interventions are recommended for sustained outcomes.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Structured Storytelling on Social Skills and Social Adaptation in Hospitalized Children with Chronic Illnesses: A Quasi-Experimental Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 10:50:13","doi":"10.21203/rs.3.rs-8104834/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-26T11:54:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304559725673861196544278734240696938385","date":"2026-01-26T08:49:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-23T17:32:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33938826646881937825124460519459449538","date":"2026-01-23T16:54:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T04:51:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-02T13:06:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-02T13:00:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-27T06:16:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-12-27T06:13:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e0576746-e5a2-4eba-835d-8ae946bdd07b","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T10:50:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 10:50:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8104834","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8104834","identity":"rs-8104834","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}