Abstract
This study aimed to conduct a meta-analysis on the effectiveness of cognitive behavioral play therapy on social skills of children with intellectual disabilities in Iran. In this meta-analysis study, the PRISMA method was used to define the decision-making process and organize the stages of study selection. Then, the effect size of mean differences and the effect size of play therapy-based interventions were determined. Among the 19 studies conducted in Iran, 12 were selected for meta-analysis. These studies were indexed in reputable scientific databases, including Jihad University Scientific Information Database, Iran Medical Articles Database, Research Institute for Information Science, Google Scholar, Iran Scientific Documents Database, and the National Journals Database, covering the period from 2008 to 2024. These studies met the inclusion and exclusion criteria and were deemed methodologically sound, ensuring their validity for meta-analysis. In this study, the meta-analysis checklist was used as the main tool for data evaluation and selection. The comprehensive meta-analysis software was utilized for descriptive data analysis and effect size calculation in this study. The study findings showed that the effect size of mean difference rate of intervention based on play therapy on the social skills was 0.58 (p≤0.0001). According to Cohen's table, this value indicates a high effect size, demonstrating a significant impact of the intervention. The results of this meta-analysis support the effectiveness of cognitive behavioral play therapy in enhancing the social skills of children with intellectual disabilities. Therefore, educational programs based on cognitive behavioral play therapy appear to be an effective approach for empowering children with intellectual disabilities in social environments. These programs can be utilized in educational centers to enhance their social skills and interactions.
Keywords: Cognitive behavioral, Intellectual disability, Meta-analysis, Play therapy, Social skills.



Extended Abstract

Introduction

Ongoing social and cultural changes present individuals with intellectual disabilities with unique and multifaceted challenges in psychological, social, and educational domains (Kirk et al., 2015). Social skill acquisition is a significant domain affected by intellectual disability, influencing the achievements and capabilities of children and adolescents (Jalil-Abkenar et al., 2012). Social skills encompass a range of behaviors and communicative strategies that facilitate successful interactions (Gresham et al., 2006). Most children acquire social skills naturally through everyday interactions with parents, siblings, and peers without formal instruction (Bryan, 2002). However, children with intellectual disabilities often face difficulties in acquiring these skills, which frequently results in negative responses from adults and peers. Deficits in social skills and significant behavioral problems can lead to dysfunctional interpersonal interactions and disruptions in the social development process (Ahghar et al., 2013). Particularly in children with intellectual disabilities, this condition not only affects interpersonal relationships but also has significant implications for family interactions and the dynamics of the family system (Totsika et al., 2022). One major risk is that these children may become trapped in a cycle of negative interactions, where they are increasingly subjected to and engage in harassment by both teachers and peers (Kauffman & Landrum, 2013). Play therapy-based interventions are considered effective in rehabilitation, holding a prominent position from educational and therapeutic perspectives, particularly in enhancing social skills (Vosoughi et al., 2025; Hoshina et al., 2017). This approach helps children express their emotions indirectly, thereby reducing psychological stress and fostering effective coping skills for emotional and behavioral challenges (Shahzadehahmadi et al., 2024). Play therapy is a significant approach in the education of children with special needs (Gupta et al., 2023). Emphasizing active participation, this method focuses on enhancing self-regulation, improving social interactions, increasing behavioral management, fostering responsibility, and strengthening social skills (Wong et al., 2023). Although numerous studies have examined the impact of play therapy, findings have reported a wide range of effectiveness, from minimal to highly significant. Therefore, conducting a meta-analysis can help determine the precise effectiveness of these interventions by systematically aggregating findings, paving the way for a deeper understanding of their role in social development.

Literature Review

The findings of Hoshina et al. (2017) indicated that digital play therapy enhances children's attention and social skills. According to Chapman and Snell (2011), social skills training and behavior modification have a positive impact on establishing interpersonal relationships and play-related skills in preschool children with special needs. Similarly, Landreth et al. (2009) indicated that play therapy positively impacts children's behavior and emotional regulation, recognizing it as one of the most effective interventions for addressing behavioral problems and fostering social skills. The results of the study by Ahmari et al. (2023) demonstrated that parent-child relationship-based play therapy had a positive effect on the social adjustment and social skills of students with intellectual disabilities and visual impairments. Furthermore, Heydari et al. (2024) found that parent-child interaction therapy based on the Eyberg approach led to improvements in anxiety levels and social skills among children with intellectual and developmental disabilities. Finally, Azarnioshan et al. (2012) demonstrated a significant positive effect of cognitive-behavioral play therapy in reducing behavioral problems among elementary school students with intellectual disabilities.

Methodology

In this study, a meta-analysis method was employed. This approach enables the integration and analysis of findings from multiple studies, providing a more comprehensive overview of the effectiveness of the interventions under investigation. The statistical population consisted of articles published in scientific journals between 2008 and 2024, focusing on the effectiveness of cognitive-behavioral play therapy on the social skills of children with intellectual disabilities in Iran. The quality of the articles was assessed based on the PRISMA statement. After removing duplicate and overlapping articles, a total of 12 studies remained for analysis. Inclusion criteria encompassed clearly defined hypotheses, a scientifically sound research design with a precise definition of the target population, an appropriate sample size, a valid sampling method, the use of measurement instruments with established validity and reliability, the application of standard statistical procedures, and the accuracy of statistical computations. Moreover, selected studies were required to focus specifically on cognitive-behavioral play therapy interventions and be conducted as group-based research employing experimental or quasi-experimental designs. Conversely, studies that lacked the necessary methodological criteria—such as case reports, reviews, correlational or descriptive studies, or those that failed to report effect sizes or provide sufficient data for their calculation—were excluded from the analysis.

Results

The results of the meta-analysis on the effectiveness of cognitive-behavioral play therapy on the social skills of children with intellectual disabilities are reported in Table 1.

Meta-analytic findings on the effectiveness of cognitive-behavioral play therapy on social skills




Research


Significance level of the studies


Conversion of significance level to z


Conversion of z to r


Cohen's d


Conversion r to Z_r


Converting z to combined significance levels


Mean effect size






1


0.001


3.090


0.39


0.85


0.412


0.0001


0.58




2


0.001


3.090


0.56


1.35


0.633




3


0.001


3.090


0.47


1.06


0.510




4


0.001


3.090


0.48


0.72


0.354




5


0.001


3.090


0.56


1.35


0.633




6


0.001


3.090


0.69


1.91


0.848




7


0.003


3.090


0.58


1.42


0.663




8


0.003


3.090


0.58


1.42


0.663




9


0.0001


3.719


0.58


1.42


0.663




10


0.0001


3.719


0.73


2.14


0.929




11


0.0005


3.719


0.68


1.85


0.829




12


0.001


3.090


0.63


1.62


0.741





Based on the data presented in the table, the effect of the independent variable (cognitive-behavioral play therapy) on the dependent variable (social skills) was found to be 0.58. According to Cohen’s criteria for effect size interpretation, this value is considered large, with a significance level of p < 0.001. Therefore, the results of this meta-analysis indicate that cognitive-behavioral play therapy has a significant impact on enhancing the social skills of children with intellectual disabilities.

Discussion

This study aimed to conduct a meta-analysis on the effectiveness of cognitive-behavioral play therapy in improving the social skills of children with intellectual disabilities. The findings revealed that the effect size of cognitive-behavioral play therapy on social skills was 0.58, which, according to Cohen’s classification, is considered a large effect. These results regarding the high effectiveness of cognitive-behavioral play therapy are consistent with the findings of Barzani and Moghadam (2012), Fallah et al. (2013), and Sadipour et al. (2019), who demonstrated the positive impact of cognitive-behavioral play therapy on the social skills and adjustment of educable female students with intellectual disabilities.

Conclusion

Given the effect size obtained in this meta-analysis, it can be concluded that cognitive-behavioral play therapy interventions have a positive and significant effect on improving the social skills of children with intellectual disabilities. However, analyzing these results highlights the importance of examining the variations in effectiveness across different interventions to determine which types are most effective and under what conditions they exert the greatest impact. Generally, children with special needs, particularly those with intellectual disabilities, face significant challenges in social skills. The findings of this meta-analysis support the efficacy of cognitive-behavioral play therapy in addressing these challenges. Consequently, play therapy-based educational programs can be utilized as an effective approach to enhance and strengthen social skills in educational centers nationwide, including special education schools.