Effects of repetitive transcranial magnetic stimulation plus sandplay therapy on children with autism spectrum disorder

Abstract

BACKGROUND

Current interventions demonstrate limited efficacy in children with autism spectrum disorder (ASD), highlighting the need to explore more effective therapeutic approaches.

AIM

To investigate the effects of repetitive transcranial magnetic stimulation (rTMS) plus sandplay therapy on developmental levels and autism severity in children with ASD.

METHODS

A retrospective analysis was conducted in 109 children with ASD enrolled between November 2023 and November 2025. The control group comprised 53 children who received sandplay therapy alone, whereas the observation group included 56 children who received rTMS in addition to sandplay therapy. Developmental levels were assessed using the Psychoeducational Profile-Third Edition (PEP-3), autism severity using the Childhood Autism Rating Scale (CARS) and Autism Behavior Checklist (ABC), intervention efficacy using the Autism Treatment Evaluation Checklist (ATEC), sociability using the Social Responsiveness Scale (SRS), and sleep quality using the Chinese version of the Children’s Sleep Habits Questionnaire (CSHQ).

RESULTS

Following intervention data, PEP-3 scores in the observation group were significantly higher than both pre-intervention results and those in the control group. In contrast, CARS, ABC, ATEC (speech/language communication, sociability, health/physical/behavior, and total score, excluding sensory/cognitive awareness), SRS (social awareness, social cognition, social communication, social motivation, autistic mannerisms, and total score), and CSHQ scores were significantly lower than both pre-intervention results and those in the control group.

CONCLUSION

rTMS combined with sandplay therapy improves developmental levels in children with ASD and effectively alleviates autism severity, supporting its potential clinical application.

Key Words: Autism spectrum disorder; Children; Repetitive transcranial magnetic stimulation; Sandplay therapy; Developmental level; Autism severity

Core Tip: To further improve intervention outcomes in children with autism spectrum disorder, this study evaluated the combination of repetitive transcranial magnetic stimulation and sandplay therapy. Compared with sandplay therapy alone, the combined intervention yielded significantly greater improvements in children’s developmental level, intervention efficacy, and sociability. It also reduced autism severity and improved sleep quality.

INTRODUCTION

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder characterized by deficits in communication and social interaction, often accompanied by restricted behaviors, interests, and activity patterns[1]. These symptoms frequently persist into adulthood, affecting individual development and imposing varying degrees of burden on families and society[2]. Epidemiological data indicate that ASD affects approximately 1 in 100 children. Clinical symptoms typically appear between 18 months and 24 months of age, although the average age of diagnosis is 4 years and 3 months[3]. The economic burden is also substantial, with lifetime treatment costs estimated at up to $2 million per child in Saudi Arabia and $2.2 million–$2.4 million per child in the United Kingdom and the United States[4]. The etiology of ASD is complex and has been consistently associated with both genetic and environmental factors[5]. Numerous clinical interventions are currently available, including applied behavior analysis, structured education, interpersonal relationship development interventions, and critical behavior training[6]. Although these approaches provide clinical benefits, their effectiveness varies according to intervention type, participant characteristics, and implementation fidelity[7]. Consequently, there remains a need to identify more effective intervention strategies for children with ASD.

Sandplay therapy is a psychological intervention based on Jungian analytical psychology and the World Technique. It explores a child’s inner world through sandplay creations and facilitates emotional expression and psychological release through guided interaction[8]. When incorporated into rehabilitation programs, sandplay therapy has been reported to enhance social interaction and emotional expression in children with ASD while promoting neural development through tactile stimulation, thereby alleviating autistic behaviors[9]. Previous studies have also reported that its application in school-age children with chronic diseases can alleviate social behavioral issues[10]. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive physical therapy that delivers magnetic stimulation to cerebral and peripheral neuromuscular structures through, promoting the normalization of neural function[11]. A systematic review reported that rTMS can reduce both core and associated ASD symptoms while improving verbal and social communication abilities[12]. Its therapeutic effects may be related to positive effects in functional brain network architecture, including enhanced long-range functional connectivity in the alpha band and increased local and global network efficiency in the delta, theta, and alpha bands[13].

However, studies evaluating the combined effects of rTMS and sandplay therapy on developmental levels and autism severity in children with ASD remain limited. Therefore, this study aimed to investigate the effectiveness of this combined intervention to evidence for optimizing treatment strategies in children with ASD.

MATERIALS AND METHODS

Case selection

A retrospective analysis was conducted on 109 children with ASD who were admitted to the Children’s Hospital Affiliated to Zhengzhou University between November 2023 and November 2025. The control group comprised 53 children who received sandplay therapy alone, whereas the observation group included 56 children who received rTMS intervention in addition to sandplay therapy. No statistically significant differences in baseline characteristics were observed between the groups (P > 0.05), indicating good clinical comparability. Inclusion criteria: Meeting the diagnostic criteria for ASD according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition[14]; age 3-7 years; normal electrocardiogram and electroencephalogram findings; ability to cooperate with all assessments and treatments; absence of active intracranial lesions; no contraindications to rTMS; and complete clinical data. Exclusion criteria: Presence of metallic implants; history of intracranial surgery; acute or chronic developmental disorders; visual or auditory impairment; diseases affecting vital organs (e.g., heart, liver, or kidneys); serious somatic diseases; or genetic and metabolic disorders.

Intervention methods

The control group received sandplay therapy. All sessions were conducted in a standardized sandplay therapy room equipped with record sheets, a digital camera, two standard sand trays (dry and wet sand), four sand-toy racks, and more than 3600 type A sand toys. All counselors held professional counseling qualifications, with a minimum of 200 hours of personal psychotherapy and casework experience, and had undergone specialized sandplay therapy training. At the beginning of each session, the counselor and child first introduced themselves to establish a positive social relationship, followed by one minute of tactile sand exploration. The child was then encouraged to select preferred sand toys, while the counselor described the characteristics of the selected toys. Throughout the creative process, the counselor observed the child’s behavior and provided companionship and support. After the artwork was completed, the counselor explored the child’s inner world based on the artwork and sand materials chosen, guiding the child to share the creative process and express feelings. Finally, the counselor photographed the completed artwork for documentation before dismantling it together with the child, concluding the session. Sandplay therapy sessions were conducted once weekly for six months, totaling ≥ 20 sessions.

The observation group received rTMS intervention in addition to the sandplay therapy regimen. Professional technicians administered rTMS using a pulsed magnetic field stimulator. The left dorsolateral prefrontal cortex was first stimulated at 10 Hz for 6 minutes, delivering 900 pulses, followed by stimulation of the right dorsolateral prefrontal cortex at 1 Hz for 12 minutes, delivering 600 pulses. Participants were instructed not to wear metal jewelry during rTMS sessions. The intervention was administered once daily, five times weekly, for six months, totaling ≥ 30 sessions.

Data collection and outcome measures

Developmental levels were assessed using the Psychoeducational Profile-Third Edition (PEP-3), which evaluates characteristics of verbal behaviors, characteristics of motor behaviors, social reciprocity, affective expression, visual-motor imitation, gross motor skills, fine motor skills, cognitive verbal/preverbal abilities, expressive language, and receptive language. Scores are proportional to functional performance.

Autistic severity: Autism severity was assessed using the Childhood Autism Rating Scale (CARS) and the Autism Behavior Checklist (ABC). The CARS comprises 15 items with a total score of 15-60 points and uses a 4-level scoring system. Assessments were performed by child psychologists with more than three years of professional experience and specialized training. A total score of 30-36 indicate mild-to-moderate autism, whereas scores > 36 with ≥ 3 points in ≥ 5 items indicate severe autism. The ABC comprises 57 items across five domains: Sensory behaviors, relating behaviors, body and object use, language skills, and social and self-help skills, with a total score of 0-158. A 4-level scoring system was used, and scores were provided by the child’s family. Scores ≥ 67 indicate a high suspicion of autism. All assessments were performed before treatment and again six months after treatment.

Intervention effects: Intervention efficacy was evaluated using the Autism Treatment Evaluation Checklist (ATEC), which comprises four dimensions: Speech/language communication, sensory/cognitive awareness, sociability, and health/physical/behavior. Total score was 0-179 points, with lower scores indicating milder autism severity and better intervention effects.

Sociability: Sociability was assessed before and after treatment using the Social Responsiveness Scale (SRS), which includes the domains of social awareness, social cognition, social communication, social motivation, and autistic mannerisms. The total score was 0-195, was higher scores indicating more severe social impairments.

Sleep status: Sleep quality was evaluated before and after intervention using the Chinese version of the Children’s Sleep Habits Questionnaire (CSHQ). The CSHQ comprises 48 items across eight dimensions, with a total score of 33-99. Higher scores indicate poorer sleep quality.

Statistical analysis

Data were analyzed using SPSS version 24.0. Categorical variables were expressed as n (%) and compared using the χ² test. Continuous variables were expressed as mean ± SD or median (interquartile range). Intergroup comparisons were performed using the independent-samples t-test or Mann-Whitney U test, whereas intragroup comparisons before and after intervention were performed using the paired t-test. A two-sided P < 0.05 was considered statistically significant.

RESULTS

Comparative analysis of general data

No significant differences were observed between the control and observation groups regarding age, sex, disease duration, ASD severity, parental education level, or place of residence (P > 0.05), indicating good baseline comparability between the groups (Table 1).

Table 1 Comparative analysis of general data, n (%)/mean ± SD.

Item	Control group (n = 53)	Observation group (n = 56)	χ2/t/Z	P value
Age (years)	6.00 (5.00, 6.00)	5.00 (4.25, 6.00)	-0.984	0.325
Gender			0.281	0.596
Male	32 (60.38)	31 (55.36)
Female	21 (39.62)	25 (44.64)
Disease duration (month)	22.64 ± 10.47	21.23 ± 8.73
ASD severity			0.371	0.542
Mild to moderate	34 (64.15)	39 (69.64)
Severe	19 (35.85)	17 (30.36)
Developmental quotient	85.11 ± 6.45	83.79 ± 6.20	1.089	0.278
Parental education level			0.177	0.674
Below high school	32 (60.38)	36 (64.29)
High school or above	21 (39.62)	20 (35.71)
Place of residence			0.197	0.657
Urban	29 (54.72)	33 (58.93)
Rural	24 (45.28)	23 (41.07)

ASD: Autism spectrum disorder.

Comparative analysis of developmental levels

Before intervention, PEP-3 scores differed insignificantly between the control and observation groups (68.55 ± 25.03 points vs 75.52 ± 21.43 points; P > 0.05). Following treatment, PEP-3 scores increased significantly in both groups and were significantly higher in the observation group than in the control group (111.71 ± 28.30 points vs 97.08 ± 22.09 points; P < 0.05) (Figure 1).

Figure 1 Comparative analysis of developmental levels. Psychoeducational Profile-Third Edition scores before and after intervention in the control group and the observation group. ^aP < 0.05, ^bP < 0.01 vs before intervention. ^cP < 0.05 vs the control group. PEP-3: Psychoeducational Profile-Third Edition.

Comparative analysis of autistic severity

Prior to intervention, no significant differences were observed between the control and observation groups in CARS [(40.81 ± 4.92) points vs (40.84 ± 5.57) points] or ABC scores [(70.11 ± 7.65) points vs (69.29 ± 6.83) points] (P > 0.05). After treatment, both groups showed significant reductions in CARS and ABC scores, with significantly lower scores in the observation group than in the control group (CARS: 30.07 ± 4.17 points vs 36.08 ± 5.03 points; ABC: 35.00 ± 4.06 points vs 39.04 ± 4.30 points; P < 0.05) (Figure 2).

Figure 2 Comparative analysis of autistic severity. A: Childhood Autism Rating Scale scores before and after intervention; B: Autism Behavior Checklist scores before and after intervention. ^aP < 0.05, ^bP < 0.01 vs before intervention. ^cP < 0.05 vs the control group. CARS: Childhood Autism Rating Scale; ABC: Autism Behavior Checklist.

Comparative analysis of intervention effects

Before intervention, ATEC scores across all dimensions showed no statistically significant intergroup differences (speech/Language communication: 16.09 ± 3.50 points vs 15.11 ± 4.03 points; sensory/cognitive awareness: 20.36 ± 4.90 points vs 19.39 ± 5.73 points; sociability: 15.98 ± 3.65 points vs 15.86 ± 3.77 points; autistic mannerisms: 24.55 ± 4.95 points vs 25.59 ± 5.70; total: 76.98 ± 9.68 points vs 75.95 ± 8.05 points; P > 0.05). After intervention, ATEC scores decreased significantly in both groups (P < 0.05). Compared with the control group, the observation group demonstrated significantly lower scores in all dimensions except sensory/cognitive awareness (speech/language communication: 10.55 ± 2.76 points vs 12.49 ± 3.28 points; sensory/cognitive awareness: 17.57 ± 3.04 points vs 17.32 ± 3.60 points; sociability: 7.82 ± 2.14 points vs 10.92 ± 2.70 points; autistic mannerisms: 16.55 ± 4.26 points vs 19.57 ± 5.95 points; total: 52.50 ± 6.38 points vs 60.30 ± 8.25 points; all P < 0.05) (Figure 3).

Figure 3 Comparative analysis of intervention effects. A: Speech/Language communication scores before and after intervention; B: Sensory/cognitive awareness scores before and after intervention; C: Sociability scores before and after intervention; D: Health/physical/behavior scores before and after intervention; E: Total Autism Treatment Evaluation Checklist scores before and after intervention. ^aP < 0.05, ^bP < 0.01 vs before intervention. ^cP < 0.05 vs the control group. ATEC: Autism Treatment Evaluation Checklist.

Comparative analysis of sociability between the two groups

No statistically significant intergroup differences were observed in SRS scores across any dimension before intervention (social awareness: 13.25 ± 2.29 points vs 13.29 ± 2.52 points; social cognition: 17.36 ± 3.36 points vs 17.54 ± 3.84 points; social communication: 33.40 ± 5.11 points vs 33.23 ± 5.66 points; social motivation: 16.74 ± 2.29 points vs 16.68 ± 2.04 points; autistic mannerisms: 18.00 ± 3.01 points vs 18.07 ± 3.04 points; total: 98.74 ± 8.32 points vs 98.80 ± 7.69 points; P > 0.05). After treatment, SRS scores decreased significantly across all dimensions in both groups and were significantly lower in the observation group than in the control group (social awareness: 10.27 ± 2.02 points vs 11.60 ± 2.66 points; social cognition: 13.57 ± 2.12 points vs 15.15 ± 2.62 points; social communication: 27.12 ± 4.09 points vs 29.68 ± 4.58 points; social motivation: 12.29 ± 2.45 points vs 14.66 ± 3.11 points; autistic mannerisms: 14.55 ± 2.67 points vs 16.45 ± 3.56 points; total: 77.80 ± 6.79 points vs 87.55 ± 8.51 points; P < 0.05) (Figure 4).

Figure 4 Comparative analysis of sociability. A: Social awareness scores before and after intervention; B: Social cognition scores before and after intervention; C: Social communication scores before and after intervention; D: Social motivation scores before and after intervention; E: Autistic mannerisms scores before and after intervention; F: Total Social Responsiveness Scale scores before and after intervention. ^aP < 0.05, ^bP < 0.01 vs before intervention. ^cP < 0.05 vs the control group. SRS: Social Responsiveness Scale.

Comparative analysis of sleep status

No statistically significant intergroup differences were observed in CSHQ scores before intervention (50.79 ± 6.80 points vs 50.39 ± 7.17 points; P > 0.05). After intervention, CSHQ scores decreased significantly in both groups and were significantly lower in the observation group than in the control group (42.20 ± 4.17 points vs 45.34 ± 5.29 points; P < 0.05) (Figure 5).

Figure 5 Comparative analysis of sleep status. Children’s Sleep Habits Questionnaire scores before and after intervention in the control group and the observation group. ^aP < 0.05, ^bP < 0.01 vs before intervention. ^cP < 0.05 vs the control group. CSHQ: Children’s Sleep Habits Questionnaire.

DISCUSSION

Children with ASD commonly exhibit social deficits characterized by difficulties in understanding others’ emotions and intentions, reduced flexibility in social interactions, and challenges in establishing and maintaining interpersonal relationships. These impairments often contribute to social isolation and reduced quality of life[15]. Therefore, this study investigated whether rTMS combined with sandplay therapy could provide greater therapeutic benefits than sandplay therapy alone. The findings consistently demonstrated superior clinical outcomes with the combined intervention across developmental, behavioral, social, and sleep-related domains.

PEP-3 assessments revealed that the combined intervention more effectively improved developmental levels of children with ASD, as reflected by higher post-intervention PEP-3 scores). Simarly, CARS and ABC results indicated greater reductions in autism severity, while ATEC results demonstrated broader improvements in intervention outcomes across multiple dimensions. These benefits may be attributable to the complementary mecahnisms of the two interventions. Sandplay therapy facilitates the expression of children’s inner experiences and emotional needs through sand trays, whereas rTMS effectively modulates neural activity within the dorsolateral prefrontal cortex. Together, these interventions leverage both psychological and neurophysiological pathways, promoting neurodevelopment and synergistically enhancing overall therapeutic efficacy. The combined intervention also significantly enhanced sociability in children with ASD compared with sandplay therapy alone, as evidenced by significantly lower SRS scores. This effect stems from the sandplay intervention process, which provides timely positive feedback. It offers appropriate intervention when social behavioral deficits arise, thereby strengthening their social interactions. Meanwhile, rTMS intervention alleviates autistic behaviors by reducing serum levels of brain-derived neurotrophic factor and insulin-like growth factor-1 in children with ASD[16]. Additionally, rTMS can bidirectionally modulate cortical excitability and influence neural activity, thereby facilitating improvement or remodeling of functional connectivity within neural circuits[17]. It was also revealed that the combined intervention significantly improved sleep quality in children with ASD, as reflected by lower CSHQ scores). Sleep disturbances are highly prevalent in children with ASD, affecting up to 80% of patients and commonly manifesting as insomnia, parasomnias, and circadian rhythm sleep-wake disorders, which may be associated with daytime behavioral challenges and parental stress[18,19]. A mouse study indicated that ASD-related social impairments and hyposomnia may be associated with septal neuroligin 3 deficiency[20]. Consistent with the present study, Ezedinma et al[21] reported that alpha rhythm-guided rTMS effectively improved subjective sleep difficulties in children with ASD, with benefits persisting for up to four months post-intervention. rTMS can indirectly improve sleep quality by alleviating sensory abnormalities and promoting structural and functional brain remodeling in pediatric patients[22,23]. Additionally, sandplay therapy intervention allows children to express themselves and release their emotions, helping them relax both physically and mentally, thereby subsequently improve sleep.

Effective interventions for children with ASD are gaining increasing research support. Liu et al[24] reported that mother-child sandplay therapy significantly improved sleep quality and social interaction in preschool children with ASD while alleviating maternal parenting stress, offering new insights for extended application of the sandplay therapy. Similarly, a randomized controlled trial demonstrated that music therapy effectively enhances social skills and language abilities in children with ASD and may serve as a complementary therapy to conventional social skills training[25]. A longitudinal study also showed that the Early Start Denver Model significantly enhanced speech and communication abilities, promoted cognitive and social development, and reduced repetitive speech behaviors in Chinese preschool children with ASD[26].

Nevertheless, several limitations should be acknowledged. First, this was a single-center study involving only 109 children with ASD, potentially limiting sample representativeness and result generalizability. Future multi-center studies with larger sample sizes are needed to improve the robustness and applicability of the study’s results. Second, the underlying mechanisms of rTMS combined with sandplay therapy were not thoroughly explored. Additional basic and translational studies are warranted to further elucidate the mechanisms underlying the observed therapeutic effects. Finally, treatment costs were not evaluated. Future analyses examining economic outcomes may facilitate clinical implementation.

CONCLUSION

In summary, rTMS combined with sandplay therapy demonstrated greater clinical efficacy than sandplay therapy alone in children with ASD. The combined intervention significantly improved developmental levels, intervention effects, sociability, and sleep quality while reducing autism severity, supporting its potential value in clinical practice.