Document Type : Research Paper
Authors
1 Ph.D. Student in Clinical Psychology, University of Tehran, Tehran, Iran
2 Ph.D. Student in Counseling, University of Mohaghegh Ardabili, Ardabil, Iran
3 Professor, Department of Counseling, University of Mohaghegh Ardabili, Ardabil, Iran
Abstract
Abstract
The purpose of this study was to evaluate the effectiveness of cognitive behavioral play therapy and Transcranial direct-current stimulation on emotional regulation, executive functions, and communication skills in children with autism spectrum disorder. This study was a quasi-experimental design with pre-test, post-test, and control group. The statistical population consisted of all children aged 6-12 years with autism spectrum disorder who referred to special education schools, centers, and clinics in Ardabil city during the years 2022-2023. A total of 45 children with autism spectrum disorder were selected non-randomly and purposefully and randomly assigned to three groups (15 children in each group). The intervention included cognitive-behavioral play therapy and transcranial direct current stimulation. The tools of this study included the N-back computerized test, Wisconsin Card Sorting Test (WCST), Gross and John Emotion Regulation Questionnaire, and the Communication Skills Questionnaire. The findings considering the results of Bonferroni's post hoc test showed that in pairwise comparison of cognitive behavioral play therapy, Transcranial direct-current stimulation and the control group in the scores of executive functions, emotion regulation and communication skills variables, there was a significant difference between the cognitive behavioral play therapy group, Transcranial direct-current stimulation group and the control group (p<0.05). In conclusion, cognitive behavioral play therapy and Transcranial direct-current stimulation have an effect on emotional regulation, executive functions and communication skills in children with autism spectrum disorder.
Keywords: cognitive behavioral play therapy, transcranial direct-current stimulation, emotional regulation, executive functions, communication skills, autism spectrum disorder
Extended Abstract
Introduction
Autism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent deficits in social communication and interaction, along with restricted and repetitive behaviors, which significantly impair children's daily functioning and family dynamics. These challenges typically manifest as difficulties in emotional regulation, executive functions, and communication skills - critical domains for social integration and personal development. The current study aimed to examine the effectiveness of cognitive behavioral play therapy (CBPT) and transcranial direct current stimulation (tDCS) in enhancing emotional regulation, executive functions, and communication skills in children with ASD, responding to the need for integrated, non-pharmacological interventions that target these core deficits concurrently.
Research Questions
What is the effectiveness of cognitive behavioral play therapy (CBPT) and transcranial direct current stimulation (tDCS) on emotional regulation, executive functions, and communication skills in children with autism spectrum disorder (ASD)?
Is there a significant difference between CBPT and tDCS in their effectiveness for improving emotional regulation, executive functions, and communication skills in children with ASD?
Literature Review
Children with ASD frequently demonstrate significant impairments in emotional regulation, with studies suggesting that approximately 85% of individuals with ASD struggle with emotion management, leading to behavioral and social difficulties (Lee et al., 2022). Executive function deficits - particularly in working memory, cognitive flexibility, and impulse control - are commonly observed and associated with prefrontal cortex dysfunction and related neural network abnormalities (Costescu et al., 2024). Communication challenges, including problems with social cue interpretation, conversation initiation, and eye contact maintenance, often worsen social isolation (Clyde et al., 2024). Cognitive behavioral play therapy (CBPT) has demonstrated effectiveness in enhancing social and communication skills by creating a secure, play-based setting for emotional expression and social interaction practice, with research showing improved neural activity and social functioning (Chan & Ouyang, 2024; Kaur et al., 2024). Similarly, transcranial direct current stimulation (tDCS) has shown potential as an intervention, modulating prefrontal cortex activity to enhance cognitive and social outcomes in ASD (Kang et al., 2024; Han et al., 2023).
Play therapy has been shown to significantly improve social skills in children with autism by offering a structured yet adaptable environment for emotional expression and social learning (Elbeltagi et al., 2023, p. 5). However, limited research has directly compared CBPT and tDCS to assess their relative effectiveness in addressing the complex challenges of ASD, underscoring the importance of comparative studies to guide clinical decision-making.
Methodology
This study utilized a quasi-experimental design incorporating pre-test and post-test assessments with a control group. The target population comprised children aged 6-12 years with ASD diagnoses who were enrolled in special education schools, centers, and clinics in Ardabil, Iran during the 2022-2023 academic year. Using non-random purposive sampling, 45 participants were selected and subsequently randomly allocated to three experimental groups (n=15 each: CBPT, tDCS, and control). Inclusion criteria consisted of: (1) formal ASD diagnosis confirmed by both psychiatrist and psychologist, (2) parental consent, (3) normal IQ range, and (4) absence of comorbid conditions. Exclusion criteria involved missing more than two intervention sessions or voluntary withdrawal. The CBPT intervention implemented Drewes' (2009) protocol through eight weekly 60-minute sessions, while tDCS administration comprised ten 10-minute sessions delivered twice weekly over five weeks using a 2NEUROSTIM device (1-2 mA current applied to prefrontal cortex). Primary outcome measures included: the N-back Computerized Test (working memory), Wisconsin Card Sorting Test (Berg et al., 1948; cognitive flexibility), Emotion Regulation Questionnaire (Gross & John, 2003), and Communication Skills Questionnaire (Matson, 1983). MANCOVA was performed with pre-test scores as covariates to examine between-group differences, following confirmation of normality, homogeneity of variance, and regression slope assumptions (α=0.05).
Results
Both intervention groups (CBPT and tDCS) showed statistically significant improvements across all measured domains - emotional regulation, executive functions (working memory and cognitive flexibility), and communication skills - when compared to the control group. The CBPT group demonstrated particular strengths in emotional regulation and communication skills, which may be attributed to its structured play-based methodology that facilitates social learning and emotional expression. Conversely, the tDCS group showed more pronounced improvements in executive functions and social communication, likely resulting from enhanced neural activation in prefrontal cortical regions. Bonferroni-adjusted post-hoc analyses confirmed the superiority of both interventions over the control condition (p < 0.05), while revealing no statistically significant differences between CBPT and tDCS outcomes.
Table 1 Mean and Standard Deviation of Pre-test and Post-test Scores for Executive Functions, Emotional Regulation, and Communication Skills
Group
Variable
Pre-test Mean (SD)
Post-test Mean (SD)
CBPT
Executive Functions
45.12 (5.61)
52.34 (4.89)
Emotional Regulation
38.76 (6.12)
46.89 (5.43)
Communication Skills
42.45 (7.19)
50.67 (6.32)
tDCS
Executive Functions
44.89 (6.23)
53.12 (5.01)
Emotional Regulation
39.12 (5.98)
47.23 (5.67)
Communication Skills
41.89 (6.87)
51.34 (6.45)
Control
Executive Functions
45.67 (5.84)
46.12 (5.76)
Emotional Regulation
38.45 (6.34)
39.01 (6.28)
Communication Skills
42.12 (7.01)
42.89 (6.95)
Note. Data reflect significant improvements in intervention groups compared to the control group (p < 0.05)
Discussion
These findings align with existing evidence showing CBPT improves emotional regulation and communication skills through amygdala modulation and prefrontal cortex reinforcement, thereby enhancing emotion management and social interaction capabilities (Chan & Ouyang, 2024; Kaur et al., 2024). Similarly, tDCS's positive impact on executive functions and social communication corroborates research demonstrating its efficacy in optimizing prefrontal neural network functioning (Kang et al., 2024; Noroozi Homayoon et al., 2024). The absence of significant between-group differences indicates comparable effectiveness of CBPT and tDCS, despite their divergent mechanisms—CBPT employing experiential learning approaches while tDCS utilizes direct neural modulation. These outcomes highlight the value of non-pharmacological interventions for core ASD symptoms. Study limitations include uncontrolled environmental and cultural variables, along with insufficient long-term follow-up to evaluate treatment effect persistence, potentially affecting result generalizability.
Conclusion
Both CBPT and tDCS demonstrated effectiveness in enhancing emotional regulation, executive functions, and communication skills in children with ASD, providing clinically valuable non-pharmacological treatment options for therapeutic and educational applications. Future studies should incorporate larger, more diverse samples and longitudinal designs to assess treatment effect maintenance and improve the generalizability of results.
Acknowledgments
The authors gratefully acknowledge the valuable contributions of the children with ASD and their families in Ardabil who participated in this study, making this research possible through their time and commitment.
Keywords
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