The Effect of Sandplay Therapy on Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis

Background: A growing number of studies have investigated the therapeutic effect of sandplay therapy on children with Autism Spectrum Disorder (ASD); however, the findings have yielded inconsistent results, making it difficult to accurately determine its true efficacy. Methods: We systematically searched randomized controlled trials (RCTs) examining the effects of sandplay therapy on children with ASD in the PubMed, EMbase, Cochrane Library, and China National Knowledge Infrastructure databases between January 1, 2005, and June 15, 2025. Literature was screened using combinations of key terms, and target studies were identified based on strict inclusion and exclusion criteria. Data were extracted, and the methodological quality of the included studies was assessed using the Cochrane Risk of Bias tool for randomized trials (RoB 1). Results: A total of 12 RCTs involving 819 participants were included. All included studies were conducted in China. The meta-analysis results suggested that the sandplay therapy group showed better overall outcomes. Significant improvements were also observed in specific domains: language (SMD=− 2.63, 95% CI: − 3.69 to − 1.56, P < 0.001), social communication (SMD = − 6.83, 95% CI: − 8.01 to − 5.65, P < 0.001), cognition or sensation (SMD = − 3.87, 95% CI: − 4.92 to − 2.82, P < 0.001), and motor or behavior (SMD = − 6.63, 95% CI: − 8.03 to − 5.22, P < 0.001). Subgroup analyses indicated that while the format, duration, and frequency of sandplay therapy might influence the effect size variations for core symptoms in children with ASD, significant heterogeneity (I 2 > 90%) persisted within each subgroup. Conclusion: Sandplay therapy may contribute positively to improving language function, social communication, cognitive or sensory function, and motor or behavioral function in children with ASD. However, the high heterogeneity warrants cautious interpretation. Keywords: sandplay, autism spectrum disorder, children, systematic review, meta-analysis