Designing an Integrated Play Therapy Program Based on the Cognitive-Behavioral Approach and Sensory Integration for Children With Autism

Introduction

utism spectrum disorder (ASD) is a neurodevelopmental condition characterized by persistent difficulties in social communication and social interaction, together with restricted, repetitive patterns of behavior, interests, or activities, with substantial heterogeneity in clinical manifestation, developmental trajectory, adaptive functioning, and support needs. Contemporary conceptualizations increasingly emphasize that ASD cannot be adequately understood solely through observable social and behavioral symptoms, because its clinical presentation reflects complex interactions among neurodevelopmental, cognitive, sensory, motor, emotional, and environmental processes (Morris-Rosendahl & Crocq, 2020). Advances in neuroscience and computational approaches have further demonstrated the biological and functional heterogeneity underlying ASD, with neuroimaging and machine-learning research attempting to identify patterns that may improve characterization and diagnosis (Nogay & Adeli, 2020). At the same time, population-based screening studies continue to underscore the practical importance of early identification during childhood, when difficulties in communication, behavior, sensory processing, and adaptive functioning may become increasingly apparent in educational and family contexts (Hasannataj et al., 2020). This heterogeneity means that children with ASD may differ markedly in the severity and configuration of their difficulties, including theory-of-mind abilities and the extent to which impairments interfere with daily functioning (Baron-Cohen et al., 2025). Accordingly, contemporary intervention planning has shifted toward multidimensional and individualized approaches that address not only core social-communication characteristics but also the associated emotional, cognitive, sensory, motor, and family-related needs that influence participation and quality of life.

Among the clinically significant but highly variable characteristics of ASD, atypical sensory processing has received particular attention. Children with ASD may demonstrate hyperresponsivity, hyporesponsivity, sensory seeking, difficulties registering or discriminating sensory information, and problems integrating information across tactile, vestibular, proprioceptive, auditory, visual, and oral sensory systems. Comparative evidence has demonstrated that sensory-processing patterns in children with ASD differ meaningfully from those observed in children with other developmental conditions and in typically developing peers (Esteki et al., 2020). Sensory-processing difficulties are important because they do not remain confined to the sensory domain; rather, they may affect attention, learning, behavioral organization, emotional stability, motor planning, social participation, self-care, and the ability to adapt to ordinary environmental demands. In inclusive educational environments, sensory-processing difficulties may interfere directly with engagement, classroom participation, concentration, and learning outcomes (Narasimhan et al., 2026). Sensory over-responsivity, in particular, may increase distress, avoidance, physiological arousal, and behavioral dysregulation when children encounter unpredictable or intense sensory input (Yuan et al., 2022). Difficulties of this type may also extend beyond the child to caregivers and professionals who must adapt environments, routines, and expectations to support participation; therefore, education and environmental support for adults working with children who have sensory-processing difficulties are increasingly regarded as important components of intervention (Pucel, 2024).

Sensory difficulties also interact with motor and functional development. Many children with ASD experience difficulties in postural control, balance, motor coordination, praxis, fine-motor functioning, and body awareness, all of which may influence independence and participation in play and everyday activities. Parents frequently identify motor development as a meaningful area of concern because limitations in movement and motor competence can restrict participation in age-appropriate activities and increase dependence on adults (Müller et al., 2024). Sensory-motor interventions delivered through play have shown potential for improving spatial visualization and fine-motor performance in children with developmental and learning difficulties, further supporting the functional interdependence of sensory and motor systems (Ghasemian Moghaddam & Mohammadzadeh, 2024). Within ASD-specific intervention research, sensory integration has therefore emerged as an important therapeutic framework. Reviews of sensory-processing and sensory integration approaches suggest that targeted, individually calibrated sensory experiences may improve selected aspects of participation, adaptive responding, sensory modulation, and functional performance, although the magnitude and consistency of effects vary according to intervention fidelity, outcomes, and study design (Camino-Alarcón et al., 2024). Recent systematic reviews and meta-analyses have similarly reported beneficial effects of sensory integration-based interventions for autistic children in several functional domains (Lyu et al., 2025; Oh et al., 2024), while a more recent systematic review of occupational therapy interventions using Ayres Sensory Integration has strengthened the contemporary evidence base for carefully delivered, fidelity-consistent sensory integration interventions (Piller et al., 2026).

Nevertheless, the sensory integration literature also demonstrates why a purely sensory intervention may not be sufficient for all children with ASD. Sensory responses are embedded within emotional, behavioral, cognitive, interpersonal, and environmental systems. For example, a child who experiences tactile or auditory hypersensitivity may develop anticipatory anxiety, avoidance, rigid routines, emotional outbursts, or reduced willingness to participate in social and educational activities. Conversely, cognitive inflexibility, emotional dysregulation, or anxiety may intensify the child’s reactions to sensory experiences. Randomized and controlled research on sensory integration has therefore highlighted both the potential benefits and the need for careful outcome specification and individualized implementation (Randell et al., 2022). Studies combining sensory environments or sensory-based methods with conventional therapeutic services suggest that integrated service models may be clinically useful when children present with complex and overlapping needs (Awaida et al., 2024). Sensory integration has also been associated with improvements in areas beyond sensory reactivity, including language-related outcomes (Fouad et al., 2023), play participation (Kuhaneck et al., 2023), communication, social interaction, stereotyped behaviors, and motor development when delivered through sensory integration-based play therapy (Rabiei et al., 2023). Sensory diet-based play therapy has likewise been applied to vestibular modulation and balance difficulties in autistic children (Salehi et al., 2019). These findings collectively indicate that sensory intervention may be most meaningful when sensory experiences are connected to broader developmental and behavioral goals rather than treated as isolated physiological phenomena.

A second intervention tradition relevant to the complex needs of children with ASD is cognitive-behavioral therapy (CBT). CBT conceptualizes emotional and behavioral problems in relation to reciprocal interactions among thoughts, affective responses, behavior, and environmental contingencies. In autistic populations, CBT has been applied particularly to anxiety, emotional regulation, behavioral difficulties, and adaptive coping. Meta-analytic evidence suggests that CBT can reduce anxiety symptoms in individuals with ASD, although treatment effects depend on developmental level, intervention adaptation, delivery format, and the characteristics of the child (Cheng et al., 2025). Recent comparative evidence concerning emotion-regulation interventions for autistic children and adolescents further emphasizes the importance of directly addressing emotional processes rather than focusing exclusively on observable behavior (Li et al., 2026). Yet traditional verbally mediated CBT may be difficult for younger children or children who have language, attention, symbolic reasoning, or social-communication limitations. Developmentally appropriate modification is therefore essential. Challenges in delivering conventional CBT to children and adolescents have long included differences in cognitive maturity, motivation, metacognitive ability, generalization, family context, and the capacity to engage in abstract verbal discussion (Halder & Mahato, 2019).

Play provides a developmentally appropriate mechanism through which cognitive and behavioral principles can be translated into concrete, experiential, and motivating therapeutic activities. Cognitive-behavioral play therapy (CBPT) integrates structured play with cognitive restructuring, emotion recognition, problem solving, modeling, reinforcement, exposure, behavioral rehearsal, and coping-skills training. Because play constitutes a natural medium through which children communicate, explore roles, express affect, and practice behavior, it can reduce the linguistic and abstract demands that often limit conventional CBT. Empirical studies have shown that cognitive-behavioral play-based interventions can improve sustained attention, working memory, and short-term memory in children with learning disorders (Azizi et al., 2020), reduce symptoms and impulsivity in children with attention-deficit/hyperactivity disorder (Hosseinzadeh, 2021; Khatoon et al., 2020), and become more effective when child-focused techniques are integrated with parent-management strategies (Feizollahi et al., 2020). These findings are relevant to ASD because attentional regulation, cognitive flexibility, behavioral self-management, and emotional control frequently constitute important treatment targets in this population.

A growing body of ASD-specific evidence likewise supports the therapeutic value of play-based cognitive and behavioral methods. Child-centered play therapy has been associated with improvements in emotional and social skills among children with autistic disorder (Hashemipour & Mohammadi, 2018). Cognitive-behavioral play therapy has been reported to reduce challenging behaviors in children with high-functioning autism (Faramarzi & Ghanei, 2019), while cognitive-behavioral sandplay has been used to reduce difficulties in emotion recognition and improve social development in boys with ASD (Mirghafourian et al., 2022). More recent findings suggest that cognitive-behavioral play therapy can also address social anxiety and self-injurious behavior in autistic children (Hamidifard et al., 2023). Contemporary treatment-planning literature further emphasizes that play interventions should be formulated systematically around the child’s developmental profile, family context, therapeutic goals, and mechanisms of change rather than being treated as an unstructured recreational adjunct (Tasijawa & Herwawan, 2025). Similarly, systematic evidence on play-based interventions for young children with disabilities indicates that structured play may facilitate executive functioning and related self-regulatory processes when activities are deliberately aligned with developmental goals (Wardhani & Widjayatri, 2025). These findings provide a strong rationale for using play as the organizing medium through which cognitive-behavioral principles can be delivered to children with ASD.

Despite these developments, cognitive-behavioral and sensory integration approaches have frequently evolved as partially separate intervention traditions. This separation may be clinically problematic because the difficulties experienced by children with ASD are rarely compartmentalized. Sensory overload may precede anxiety, aggression, stereotypy, withdrawal, or emotional meltdown; poor sensory registration may appear behaviorally as inattention or reduced engagement; vestibular and proprioceptive difficulties may interfere with motor confidence and social play; and cognitive rigidity may make adaptation to sensory novelty especially difficult. Conversely, improved sensory organization may create a physiological state in which the child is more able to attend, engage, reflect on emotions, practice coping strategies, and participate in reciprocal interaction. Thus, an integrated model has the potential to target both bottom-up sensory-regulatory mechanisms and top-down cognitive-behavioral processes within the same therapeutic sequence. Research on combined sensory and play-oriented approaches has generated encouraging findings, although the evidence remains methodologically heterogeneous (Awaida et al., 2024; Rabiei et al., 2023). One published study also examined an intervention combining sensory integration training with social sports games, but because that report was subsequently retracted, it should not be treated as reliable evidence for intervention efficacy (Wang et al., 2022). This circumstance further highlights the need for theoretically coherent, transparently developed, and methodologically validated integrated protocols.

The rationale for integration is strengthened by ecological and family-centered perspectives. Children with ASD function within interacting family, educational, therapeutic, and community systems, and gains achieved within a clinic may have limited practical value unless they generalize to daily routines and natural environments. Family-centered occupational therapy literature emphasizes that caregivers should not merely receive information at the end of treatment but should participate meaningfully in intervention planning, implementation, and generalization (Watling et al., 2023). Function-based and communication-oriented interventions also demonstrate the value of tailoring intervention strategies to the environmental conditions and functional determinants surrounding behavior (Perihan & Bicer, 2021). Moreover, treatment delivered in routine practice requires an appropriate balance between fidelity to core therapeutic principles and flexibility in responding to individual children, families, and service contexts (Pickard et al., 2023). The systemic perspective similarly suggests that the child’s difficulties and improvements should be understood within relational and contextual networks rather than exclusively at the level of the individual child (Robinson, 2025). Accordingly, a comprehensive intervention for ASD should ideally include parental participation, environmental modification, home-based generalization, and strategies that can be individualized according to sensory and behavioral profiles.

Several Iranian studies have also documented the relevance of sensory, behavioral, emotional, and play-based interventions for children with developmental difficulties, but the literature remains fragmented across intervention modalities. Research has supported the use of cognitive-behavioral play therapy for challenging behavior (Faramarzi & Ghanei, 2019), social anxiety and self-injurious behavior (Hamidifard et al., 2023), attention and impulsivity (Hosseinzadeh, 2021), and cognitive functioning (Azizi et al., 2020). Other work has demonstrated the importance of sensory-processing differences in autistic children (Esteki et al., 2020), the therapeutic relevance of sensory integration-based play approaches (Rabiei et al., 2023), and the potential value of sensory-motor and sensory-diet interventions (Ghasemian Moghaddam & Mohammadzadeh, 2024; Salehi et al., 2019). Studies of autism screening and childhood developmental needs also reinforce the importance of early, structured, and contextually appropriate services (Hasannataj et al., 2020). Related intervention research has emphasized the value of therapeutic methods directed toward emotional, behavioral, and adaptive outcomes in children with special needs (Faramarzi & Ghanei, 2019; Feizollahi et al., 2020), while other Iranian investigations have contributed to the broader evidence base concerning psychological and developmental interventions for children and families (Ghasemian Moghaddam & Mohammadzadeh, 2024; Hamidifard et al., 2023; Hosseinzadeh, 2021; Mirghafourian et al., 2022). However, studies have rarely articulated a single protocol in which sensory integration and cognitive-behavioral play therapy are conceptually mapped to the same needs-assessment structure, translated into specific performance objectives, and sequenced across treatment sessions.

The design of such a protocol requires more than simply placing cognitive-behavioral and sensory activities side by side. A theoretically coherent integrated intervention should identify the target needs, determine their conceptual relationships, specify modifiable determinants, define observable performance objectives, and connect intervention components to explicit mechanisms and measurable outcomes. Intervention Mapping offers a systematic framework for this purpose by linking needs assessment, performance objectives, behavioral and environmental determinants, intervention methods, implementation, and evaluation in a transparent developmental sequence (Bartholomew Eldredge et al., 2022). This approach is especially appropriate for ASD because of the heterogeneity of children’s sensory, emotional, cognitive, behavioral, and family needs. It also supports a treatment architecture in which sensory preparation can be intentionally linked with cognitive-behavioral tasks, social play, emotion-regulation exercises, adaptive activities, and parent-mediated generalization rather than being implemented as unrelated techniques. Such systematic integration is consistent with emerging evidence that successful ASD intervention increasingly depends on individualized, multidomain treatment planning rather than allegiance to a single therapeutic mechanism (Camino-Alarcón et al., 2024; Li et al., 2026; Piller et al., 2026).

The available literature therefore points to an important conceptual and practical gap. Sensory integration approaches address atypical sensory modulation, sensory seeking and avoidance, praxis, and body-based regulation, whereas cognitive-behavioral play therapy can target maladaptive cognitions, emotional identification, coping skills, problem solving, behavioral regulation, and social learning. Play provides a developmentally appropriate context for integrating these mechanisms, and family participation can facilitate the transfer of treatment gains to home and community environments. However, an explicitly structured, theoretically derived, content-validated protocol that integrates these components session by session for children with ASD remains insufficiently developed. Evidence supporting sensory intervention (Lyu et al., 2025; Oh et al., 2024; Piller et al., 2026), cognitive-behavioral and emotion-focused intervention (Cheng et al., 2025; Li et al., 2026), play-based intervention (Tasijawa & Herwawan, 2025; Wardhani & Widjayatri, 2025), motor and functional intervention (Müller et al., 2024), and family-centered practice (Watling et al., 2023) provides a strong foundation for developing such an integrated model. At the same time, the diversity of individual needs and variable findings across existing studies reinforce the importance of systematic qualitative synthesis, expert validation, and explicit intervention mapping before clinical effectiveness is evaluated.

Therefore, the present study aimed to design and validate an integrated play therapy program based on the cognitive-behavioral approach and sensory integration for children with autism spectrum disorder.

Methods and Materials

The present study was applied in terms of purpose and qualitative in terms of methodology. In the qualitative phase, thematic analysis was employed to comprehensively examine the existing themes and patterns, and a comprehensive analysis of the themes obtained was ultimately presented. The statistical population of the qualitative phase consisted of university faculty members and experts in the field of children with neurodevelopmental disorders. Purposive sampling, a non-probability sampling method, was used to select the sample for the qualitative phase of the study. Purposive sampling, as employed in qualitative research, refers to the deliberate selection of individuals and study settings because they can contribute substantially to understanding the research problem and the central phenomenon under investigation (Ray & Taba, 2015). To collect information and review the research literature, Iranian and international scientific databases were searched, and relevant information was extracted from specialized Persian- and English-language articles, books, and theses concerning cognitive-behavioral play therapy, sensory integration, and neurodevelopmental disorders, including autism in children, in accordance with the objectives and hypotheses of the study. Given the purpose of the study, thematic content analysis was employed in the first stage of data collection. Thematic analysis constitutes a fundamental and core approach within qualitative analysis and serves as an introduction to other qualitative methodologies, such as grounded theory, phenomenology, and narrative inquiry (Smith, 2015). Thematic analysis is a useful and flexible method for identifying, analyzing, and reporting themes and patterns within a dataset. It is a realist method that elucidates and reports participants’ experiences, meanings, and realities. Themes represent important features of the data in relation to the research problem (Terry et al., 2017). These themes organize responses and meanings associated with the research question into identifiable patterns. Within this research design, the researcher assumes an active role and is responsible for selecting the theoretical framework, designing the questions, determining the methods of data collection, and selecting the sample. The information obtained through thematic analysis should comprehensively address the research questions. Coding, categorization, and pattern identification determine what the data indicate and thereby guide the researcher toward answering the research question. The thematic content analysis method consists of six interconnected stages, and the data derived from the reviewed studies were analyzed according to these stages in the present research (Braun & Clarke, 2012).

Stage 1: Familiarization with the Data: To analyze the data, the information obtained from the review of the theoretical foundations was first fully transcribed. During this process, any word or sentence that attracted the researcher’s attention was highlighted, and relevant notes were written in the margins.

Stage 2: Coding: The coding process was conducted manually and using Microsoft Excel. At this stage, after reviewing the information, the researcher identified and compiled common and homogeneous characteristics within the data, categorized them, and assigned semantically similar codes. The researcher attempted to continuously refine and compare the codes with an open mind and without empirical or theoretical bias in order to derive the final codes.

Stage 3: Searching for Themes: At this stage, the researcher categorized the codes according to their semantic and content similarities and selected a word or phrase for each category as the main theme representing the central message of that category. A thematic map of the themes was subsequently developed. Grouping codes under a principal theme is essential for deriving meaning from the data and developing insight into them.

Stage 4: Reviewing and Refining Themes: Following theme development, the process of categorizing codes under each theme was re-examined, and the appropriateness of each theme in relation to the associated codes and the broader context of the data was assessed. Because the selected themes were required to clearly represent the codes subsumed under them and encompass their principal meaning, repeated reviews of the codes and themes resulted in the elimination of inappropriate items and greater precision in the categorization and specification of themes.

Stage 5: Defining and Naming Themes: At this stage, after constructing the thematic map of the data, the researcher named and defined each theme. These definitions provided the reader with a concise interpretive explanation of the meaning and message of each theme. The proposed names and definitions were discussed with specialists, and the most appropriate label and definition were selected for each theme.

Stage 6: Writing the Report: At the final stage, the researcher synthesized the findings, interpreted them within the framework of the relevant research literature, and prepared the final report of the data.

The purpose of validation was to assess the accuracy of the research findings and conclusions, a process that can be conducted through various strategies in qualitative research. To evaluate the validity of the findings, researcher feedback was employed. The researcher shared the proposed codes and themes with the academic supervisors, and the findings and rationale underlying the coding and theme development were critically discussed and challenged. The themes were repeatedly reviewed against the original data context, and the final main and subthemes were extracted. To evaluate the reliability of the findings, inter-coder agreement was employed. Doctoral peers familiar with qualitative methodology were asked to independently code and develop themes from one interview without being informed of the researcher’s coding. Their assessments were then reviewed, and the necessary revisions were implemented.

For the qualitative assessment of content validity, experts were asked to evaluate the extent to which the content of the integrated cognitive-behavioral play therapy and sensory integration program for children with autism was consistent with the study objectives. Accordingly, the integrated cognitive-behavioral play therapy and sensory integration program was presented to 10 faculty members from the University of Tehran and experienced therapists working in a university clinic for children with neurodevelopmental disorders who were active in the field of autism spectrum disorder. They were asked to provide their comments on the developed package so that it could be improved.

The method proposed by Waltz and Bausell (1981) was used to calculate the Content Validity Index (CVI). In this method, experts evaluate the relevance, simplicity, and clarity of each step in the design of the integrated cognitive-behavioral play therapy and sensory integration program using a 4-point Likert scale. Specifically, the relevance of each protocol item is rated as 1 = not relevant, 2 = somewhat relevant, 3 = relevant, and 4 = highly relevant. The simplicity of each step is rated from 1 to 4, ranging from insufficient simplicity to complete simplicity, and the clarity of each item is rated as 1 = unclear, 2 = relatively clear, 3 = clear, and 4 = completely clear. For this index, the number of experts providing favorable ratings for each item is divided by the total number of experts. The minimum acceptable value for the CVI is .79. Accordingly, if the CVI for a protocol item was lower than .79, that item was revised.

In addition, to calculate the Content Validity Ratio (CVR), experts were asked to evaluate each item of the intervention protocol using a three-category scale consisting of “essential,” “useful but not essential,” and “not essential.” The responses were then calculated according to the formula CVR = Ne − N/2. Thus, the quantitative assessment of the content validity of the integrated cognitive-behavioral play therapy and sensory integration program was performed using both the Content Validity Index (CVI) and the Content Validity Ratio (CVR). The experts also communicated their assessments to the researcher by responding to a five-point questionnaire ranging from “strongly agree” to “strongly disagree.” Lawshe’s method was used to determine the degree of expert agreement on each item, and the experts were asked to determine the appropriateness of each therapeutic session using a three-category scale consisting of “essential,” “useful,” and “not essential.” The CVR was then calculated for each treatment session. To calculate the CVI, the experts were asked to rate the fluency, clarity, and relevance of the treatment sessions using a 4-point Likert scale consisting of “not relevant,” “requires major revision,” “relevant but requires revision,” and “completely relevant.”

Findings and Results

The results of the demographic analysis showed that among the faculty members participating in the study, 2 participants (20%) were aged 30–39 years, 3 participants (30%) were aged 40–49 years, and 5 participants (50%) were aged 50 years or older. Regarding professional experience, 1 participant (10%) had less than 5 years of experience, 4 participants (40%) had 5–10 years of experience, and 5 participants (50%) had more than 10 years of professional experience. In addition, 5 participants (50%) held the academic rank of assistant professor, 3 (30%) were associate professors, and 2 (20%) were full professors.

Table 1 comparatively presents the fundamental needs of children with autism spectrum disorder across 10 key domains. The findings indicate that children with autism spectrum disorder frequently experience qualitative impairments in social interaction, cognitive flexibility, and language functioning (Cheng et al., 2025).

Table 2 illustrates the systematic coding process applied to theoretical and empirical sources across four analytical levels. Following extraction of the initial codes, the code list was provided to a panel of expert faculty members in occupational therapy, child psychology, and play therapy to evaluate the content validity of the codes and their relevance to the scope of the study. This stage corresponds to the fourth phase of Braun and Clarke’s (2006) framework, namely “reviewing themes,” and is consistent with Lincoln and Guba’s (1985) principles of trustworthiness, thereby strengthening the methodological rigor of the coding process. Eight initial codes were removed by the expert panel. The reasons for their exclusion can be organized into four methodological categories.

First, being outside the scope of the study: Codes 53, 54, and 59 referred to issues that were medical-physiological in nature and could not be directly targeted through the components of cognitive-behavioral play therapy and sensory integration. These conditions require specialized medical referral, and their inclusion would have weakened the focused validity of the protocol.

Second, overlap and redundancy: Codes 56 and 57 represented more specific examples of previously extracted axial codes. Retaining them would have produced unnecessary redundancy and reduced conceptual differentiation among categories; therefore, they were integrated into the relevant axial codes.

Third, confusion between diagnosis and need: Code 58 represented a comorbid diagnostic label rather than an intervention-relevant need. The analytical framework was designed to extract “needs,” rather than document diagnostic characteristics; consequently, this code was considered inconsistent with the fundamental logic of the needs assessment.

Fourth, weak scientific support and conceptual ambiguity: Codes 55 and 60 either appeared very infrequently in the reviewed sources and failed to achieve theoretical saturation (Code 55), or lacked a clear theoretical foundation in the core sensory integration literature and could not be clearly differentiated from other constructs (Code 60).

The systematic exclusion of these eight codes and transparent documentation of the reasons for their removal should be regarded not as a methodological deficiency but as evidence of rigor and methodological discipline, thereby enhancing the auditability of the qualitative analysis. Accordingly, the final set of 52 retained initial codes resulted from a purposeful refinement process in which only those codes with sufficient scientific support, clear conceptual distinctiveness, and relevance to the scope of the study were retained. The 52 extracted initial codes constituted fundamental units of meaning directly derived from the scientific literature. These codes were subsequently categorized into 22 axial codes representing shared conceptual patterns. This process is fully consistent with the principles of deductive-inductive thematic analysis (Braun & Clarke, 2006) and supports the content validity of the coding process. The diversity of scientific sources used, ranging from Ayres’ classic work (1972) to contemporary studies (Lang et al., 2012; Wardani & Widyatri, 2025), reflects comprehensive coverage of the relevant literature. The 14 identified subthemes were integrated into eight main themes constituting the conceptual framework of the integrated protocol. These themes were: (1) fundamental sensory processing, (2) emotional and behavioral regulation, (3) social interaction and communication, (4) cognition and learning, (5) motor and bodily integration, (6) oral sensory processing, (7) daily functioning and independence, and (8) family and social support.

Table 3 presents the eight main themes derived from the thematic analysis process together with their subthemes, applications within the protocol, and scientific documentation. These themes constitute the core pillars of the integrated protocol, with each theme linked to specific sessions of the 12-session intervention. The sequence progresses from more foundational themes, such as fundamental sensory processing, toward more advanced themes, such as daily functioning and independence, which is consistent with the developmental sequencing principle in occupational therapy interventions (Ayres, 1972).

Analysis of the components of cognitive-behavioral play therapy indicates that this approach is grounded in Beck’s (1979) cognitive model, according to which thoughts, emotions, and behaviors interact within an integrated system. Within the play therapy framework, this model is operationalized through activities that enable the child to identify dysfunctional thinking patterns within the context of play and replace them with more realistic thoughts (Rotheram-Fuller & McMullen, 2011). This process is particularly important for children with autism spectrum disorder, who frequently demonstrate cognitive distortions and limited flexibility, because play, as the child’s natural language, may reduce resistance to cognitively oriented therapeutic interventions.

Ayres’ (1972) sensory integration theory proposes the fundamental principle that effective brain functioning requires the reception, processing, and integration of sensory information from multiple sources. In children with autism spectrum disorder, this integrative process is impaired, leading to maladaptive sensory responses that can subsequently have negative effects on behavior, emotion, and learning (Schaaf & Miller, 2005). Sensory integration intervention provides purposeful and organized sensory experiences intended to stimulate neuroplasticity and gradually enhance the child’s sensory-processing capacity. Neuroimaging evidence has indicated that such interventions may be associated with positive structural and functional changes in sensory cortical regions (Lang et al., 2012).

The reciprocal and synergistic relationship between the two therapeutic approaches can be explained from a neuropsychological perspective. Predictive processing theory proposes that the brain continuously constructs models of the environment and compares them with actual sensory input. This modeling process is impaired in children with autism spectrum disorder (Baron-Cohen et al., 2025). Integrating cognitive-behavioral play therapy, which targets higher-order cognitive processes, with sensory integration, which optimizes sensory input, may therefore address both dimensions of the disorder. This synergy is supported by the findings of Wardani and Widyatri (2025), who reported that combined interventions produced more substantial improvements in sensory-processing indicators than single-approach interventions.

Table 5 illustrates the systematic relationship among initial codes, axial codes, subthemes, and main themes and their connection to the sessions of the 12-session protocol. The table demonstrates that each main theme is addressed across multiple sessions, which is consistent with the principles of repetition and consolidation in learning (Braun & Clarke, 2006). The theme of “fundamental sensory processing,” which contained the largest number of initial codes, is represented from the first through the seventh session, whereas “family and social support” operates as a parallel component throughout all sessions. This distribution pattern reflects a comprehensive understanding of the relative importance and logical sequencing of each theme within the therapeutic change process.

According to the intervention design framework, or Intervention Mapping (Bartholomew Eldredge et al., 2022), after the main themes were extracted, the process of transforming the identified needs into performance objectives and change objectives began. Performance objectives specify the behaviors that the child should demonstrate by the end of the intervention, whereas the change matrix identifies which determinants—cognitive, emotional, behavioral, and sensory—must change in order for each objective to be achieved. Together, these two tools provide a detailed roadmap for designing intervention strategies.

Table 6 presents the protocol’s performance objectives in accordance with SMART criteria—specific, measurable, achievable, relevant, and time-bound. Each objective is directly linked to a main theme derived from thematic analysis, and its observable indicators enable evaluation of intervention effectiveness. These indicators are aligned with validated and standardized measurement instruments, such as the Sensory Profile 2 (SP-2) and the Peabody Developmental Motor Scales, which have been used in established research (Bani et al., 2020; Liu et al., 2025). The specification of quantitative objectives with predetermined improvement percentages provides the scientific transparency required in intervention research.

Performance goal-setting within this protocol can be theoretically justified by Locke and Latham’s (1990) goal-setting theory, according to which challenging yet attainable goals produce the highest levels of motivation and effort. Parental participation in establishing goals is also consistent with this theory because goals developed collaboratively with stakeholders tend to produce greater adherence (Eslami et al., 2016). Attention to the generalization of goals to home and community settings also represents a key principle in designing interventions for children with developmental disorders (Watling et al., 2023).

The change matrix presented in Table 7 indicates that four categories of determinants must be modified for each performance objective in order to achieve sustainable change. Cognitive determinants, including beliefs, awareness, and knowledge; emotional determinants, including feelings and motivation; behavioral determinants, including skills and habits; and sensory determinants, including sensory-processing capacity, interact systematically with one another. This systemic understanding is fully consistent with the biopsychosocial model, which represents a dominant framework for designing interventions for children with developmental disorders (Creswell & Poth, 2018).

An important feature of the change matrix is that sensory determinants are presented as an independent dimension equivalent in importance to the other determinants. This represents a conceptual innovation of the integrated protocol because the sensory dimension is commonly overlooked in traditional cognitive-behavioral interventions. By incorporating sensory determinants into the change matrix, the present protocol addresses a fundamental limitation of existing approaches. This perspective is fully consistent with the findings of Lang et al. (2012), who demonstrated that sensory processing plays a central role across multiple dimensions of functioning in children with autism spectrum disorder.

1. Structure of Each Session: Each session of the integrated protocol lasts approximately 60–75 minutes and consists of four principal components: (a) opening/sensory warm-up (10–15 minutes), including organizing sensory activities intended to prepare the nervous system; (b) main play activity (30–35 minutes), targeting the principal session objectives through integrated, goal-directed play activities; (c) reflection and cognitive processing (10–15 minutes), involving documentation of experiences, discussion of emotions, and cognitive processing; and (d) homework and parent education (5–10 minutes), including the assignment of generalization tasks and brief parental instruction.

2. Session Framework: The 12-session protocol is organized into three phases. Phase 1 (Sessions 1–4), assessment and foundation building, includes sensory-profile assessment, establishment of a safe therapeutic relationship, and introduction of basic concepts related to sensory and emotional processing. Phase 2 (Sessions 5–9), intervention and skill acquisition, includes active sensory interventions, cognitive-behavioral strategy training, and work on social skills. Phase 3 (Sessions 10–12), generalization and consolidation, includes practicing skills in real-life situations, more intensive parent training, and planning for maintenance of treatment gains.

The final conceptual model of the integrated cognitive-behavioral play therapy and sensory integration protocol for children with autism spectrum disorder and sensory modulation disorder can be conceptualized as a three-layer system. The first layer, or foundation, consists of fundamental sensory processing, which influences all other aspects of the child’s functioning. Improvement at this level facilitates development within the subsequent layers. The second, intermediate layer includes emotional and behavioral regulation, social interaction, and cognition and learning, all of which interact reciprocally. Improvement in each dimension facilitates development in the others. The third, applied layer consists of daily functioning and independence, representing the ultimate outcome and overarching objective of the intervention.

The two principal therapeutic axes—cognitive-behavioral play therapy and sensory integration—do not operate in parallel but rather progress in a spiral pattern. Both approaches are present in each session, although their relative emphasis changes according to the specific objective of the session. Play serves as the common therapeutic context within which these two approaches are integrated. Family involvement is not considered an ancillary element but rather a parallel therapeutic axis extending throughout all 12 sessions. This conceptual model is fully consistent with the systemic approach in psychology (Robinson, 2025) and Bronfenbrenner’s (1979) ecological model, which emphasizes interactions between the child and multiple environmental systems.

Following development of the preliminary intervention, it was necessary to establish its validity before it could be used in the present study. Accordingly, the internal and external validity of the developed intervention were examined.

The internal validity of the developed intervention was evaluated using the following two procedures.

a. Member Checking: In this procedure, participants (faculty members) were asked to evaluate the descriptions of the intervention sessions developed for the study and comment on their appropriateness and consistency with the objectives of the qualitative phase. Based on their comments and feedback, the strengths and weaknesses of the designed intervention were identified to the greatest extent possible, and the necessary revisions were made. The most important modifications made to the preliminary intervention on the basis of this feedback included improving clarity and simplifying the intervention for instructional use, expressing educational activities and assignments in more objective and specific terms, placing greater emphasis on activities and assignments directly related to the cognitive-behavioral and sensory integration approaches, revising some of the objectives assigned to individual sessions, and modifying the sequence in which educational activities and assignments were applied and implemented.

b. Calculation of the Content Validity Index (CVI): Another procedure used to examine the internal validity of the developed intervention was calculation of the CVI regarding the appropriateness of the session descriptions and the activities and assignments included in the educational intervention relative to the study objectives. For this purpose, the preliminary intervention and a 12-item questionnaire were provided to 10 specialists in instructional design, including faculty members in educational sciences with expertise in instructional design and faculty members in psychology at Islamic Azad University, Central Tehran Branch. The questionnaire items assessed the appropriateness of the session descriptions, strategies, activities, and assignments employed in the intervention relative to the objectives of the study. Experts rated each item on a four-point scale: 1 = not appropriate, 2 = relatively appropriate, 3 = appropriate, and 4 = completely appropriate.

The minimum acceptable value for the CVI is .79, and if the CVI of an item is lower than .79, that item should be eliminated (Waltz & Bausell, 1981, as cited in Seif, 2011). As shown in the table above, the Content Validity Index for all items assessing the consistency of the developed intervention with the study objectives exceeded .79. Therefore, it can be concluded that the developed preliminary intervention demonstrated satisfactory content validity.

Discussion

The present study aimed to design and validate an integrated play therapy program based on the cognitive-behavioral approach and sensory integration for children with autism spectrum disorder. The findings indicated that the systematic qualitative synthesis led to the identification of 52 retained initial codes, 22 axial codes, 14 subthemes, and eight main themes, namely fundamental sensory processing, emotional and behavioral regulation, social interaction and communication, cognition and learning, motor and bodily integration, oral sensory processing, daily functioning and independence, and family and social support. These themes were subsequently translated into an integrated 12-session intervention protocol in which cognitive-behavioral play therapy and sensory integration were combined within a structured and developmentally sequenced framework. The expert-validation phase further demonstrated acceptable content validity, with the Content Validity Index for all 12 sessions ranging from .80 to .90 and exceeding the accepted minimum criterion of .79. These findings suggest that the developed intervention possesses satisfactory conceptual coherence and content validity and that the integration of sensory and cognitive-behavioral components within a play-based structure is both theoretically defensible and practically feasible.

One of the principal findings was the central position of fundamental sensory processing within the conceptual model. Sensory-related needs accounted for a considerable proportion of the extracted codes and included hyperresponsivity, hyporesponsivity, sensory seeking, sensory avoidance, impaired tactile and vestibular processing, low registration, auditory and visual sensitivity, and difficulties with proprioceptive and oral sensory processing. This finding is consistent with evidence indicating that atypical sensory processing constitutes a major dimension of functioning in children with autism spectrum disorder and can influence behavior, learning, participation, and adaptive functioning (Esteki et al., 2020; Yuan et al., 2022). The prominence of sensory processing in the present model is also supported by systematic reviews showing that sensory integration-based interventions can improve selected functional and sensory outcomes among autistic children (Camino-Alarcón et al., 2024; Lyu et al., 2025; Oh et al., 2024). More recent synthesis of occupational therapy interventions using Ayres Sensory Integration similarly supports the continued clinical relevance of interventions that are individualized, activity-based, and directed toward meaningful participation rather than isolated sensory stimulation (Piller et al., 2026). Thus, the location of sensory processing at the foundational level of the present conceptual model is consistent with contemporary evidence suggesting that sensory regulation can affect readiness for engagement in higher-order cognitive, emotional, social, and adaptive activities.

The identification of emotional and behavioral regulation as a second major theme is likewise theoretically and empirically meaningful. Children with autism spectrum disorder frequently experience difficulties identifying emotions, modulating arousal, tolerating frustration, and regulating responses to environmental demands. In the present study, emotional meltdowns, sensory-related anxiety, low emotional tolerance, self-regulation difficulties, stereotyped self-soothing behaviors, and hyperarousal emerged as interrelated intervention targets. These findings are consistent with the growing recognition that emotion regulation should be treated as a core therapeutic target in autistic children and adolescents rather than as a secondary consequence of other symptoms (Li et al., 2026). The inclusion of cognitive-behavioral techniques such as emotion recognition, cognitive restructuring, relaxation training, graded exposure, and problem-solving is also supported by evidence indicating that cognitive-behavioral interventions can reduce anxiety and improve emotional functioning in people with autism spectrum disorder (Cheng et al., 2025). Previous studies of cognitive-behavioral play therapy have similarly reported reductions in challenging behaviors, social anxiety, and self-injurious behaviors among children with autism (Faramarzi & Ghanei, 2019; Hamidifard et al., 2023). Therefore, integrating cognitive-behavioral emotion-regulation strategies with sensory-regulation activities appears particularly appropriate for children whose emotional dysregulation may be intensified by sensory overload or poor sensory modulation.

Another important finding was the emergence of social interaction and communication as a distinct but interconnected domain. The qualitative analysis identified theory-of-mind deficits, limited understanding of nonverbal cues, poor social reciprocity, difficulty with turn-taking, restricted peer interaction, and delayed language as major intervention needs. These findings are compatible with contemporary evidence demonstrating substantial variability but persistent difficulty in theory-of-mind functioning among autistic individuals (Baron-Cohen et al., 2025). They are also consistent with prior research demonstrating that play-based and child-centered interventions can improve emotional and social skills in children with autism (Hashemipour & Mohammadi, 2018). In the present protocol, these difficulties were addressed through structured social play, role-playing, social stories, empathy training, turn-taking exercises, and opportunities for reciprocal interaction. Such strategies are theoretically appropriate because play creates a controlled but naturalistic context in which children can rehearse social scripts and receive immediate feedback. The use of role-playing and structured play is also consistent with contemporary treatment-planning approaches that emphasize developmentally adapted, goal-directed, and family-sensitive play interventions (Tasijawa & Herwawan, 2025). In addition, sensory modulation may indirectly support social participation by reducing the sensory overload that can contribute to withdrawal, irritability, or avoidance in socially demanding environments.

The theme of cognition and learning also played a substantial role in the developed protocol. The extracted codes included cognitive inflexibility, poor sustained attention, difficulty generalizing acquired skills, cognitive-sensory interference, negative thinking patterns, and limited intrinsic motivation during play. These findings are clinically important because cognitive and attentional difficulties can affect the child’s capacity to benefit from educational and therapeutic experiences. The inclusion of rule-changing games, flexible storytelling, problem-solving exercises, and generalization tasks is supported by evidence demonstrating that cognitive-behavioral play therapy can improve working memory, short-term memory, and sustained attention in children with developmental and learning difficulties (Azizi et al., 2020). Other studies have shown that cognitive play therapy can reduce impulsivity and attentional difficulties (Hosseinzadeh, 2021; Khatoon et al., 2020). Although these studies were not limited exclusively to autism spectrum disorder, they support the broader principle that cognitive functions can be addressed through structured play rather than through exclusively verbal methods. The present findings also align with systematic evidence suggesting that play-based interventions may strengthen executive functions in young children with disabilities (Wardhani & Widjayatri, 2025). The integrated protocol therefore appears to address cognitive functioning in a developmentally sensitive way while simultaneously reducing sensory barriers that may otherwise compromise attention and learning.

Motor and bodily integration formed another central component of the conceptual framework. Problems with gross-motor coordination, praxis, vestibular processing, proprioception, balance, and movement tolerance were repeatedly represented in the extracted codes. This finding corresponds with reports that motor difficulties are common among children with autism spectrum disorder and can affect participation, independence, and parental perceptions of the child’s developmental functioning (Müller et al., 2024). The protocol therefore included obstacle courses, bilateral coordination exercises, balance activities, controlled vestibular stimulation, deep-pressure activities, and proprioceptive input. This structure is consistent with research showing that sensory-motor integration programs can improve spatial visualization and fine-motor skills in children with developmental difficulties (Ghasemian Moghaddam & Mohammadzadeh, 2024). It is also supported by studies of sensory integration and play participation in autistic children, which suggest that individualized sensory integration can promote more effective engagement in meaningful activity (Kuhaneck et al., 2023). The inclusion of motor and bodily integration within the same framework as emotional and cognitive components is therefore justified by the reciprocal relationship between movement, arousal regulation, sensory processing, and participation.

The identification of oral sensory processing as a separate main theme also adds specificity to the intervention model. Difficulties tolerating food textures, restricted food selection, oral sensory avoidance, and oral sensory seeking were distinguished from broader sensory-processing challenges. This distinction is clinically useful because feeding-related sensory behaviors can have direct implications for daily routines, family stress, and participation in mealtimes. Sensory over-responsivity research has shown that atypical sensory reactions can be highly modality-specific and may require targeted intervention strategies rather than broad sensory stimulation (Yuan et al., 2022). By including graded oral-tactile exposure and individualized sensory activities, the developed protocol attempts to address this specificity. This approach also reflects the broader principle that sensory intervention should be individualized according to each child’s profile rather than uniformly applied.

Daily functioning and independence emerged as the applied endpoint of the intervention model. The extracted needs included dependence on fixed routines, difficulty adapting to change, problems with self-care, activity-transition difficulties, and reduced social participation. This finding is consistent with current intervention perspectives that prioritize functional participation rather than symptom reduction alone. Sensory integration therapy has increasingly been evaluated in relation to occupational and participation outcomes, and randomized evidence has emphasized the importance of determining whether intervention gains translate into meaningful daily functioning (Randell et al., 2022). The present protocol consequently incorporated home-based assignments, structured transitions, self-care tasks, and generalization exercises in the later sessions. This sequencing reflects the assumption that sensory, emotional, cognitive, and social capacities should ultimately support improved adaptation in real-life contexts. It also aligns with the principle that treatment fidelity must be balanced with contextual flexibility so that intervention procedures can be adapted to individual children and natural environments without abandoning their core mechanisms (Pickard et al., 2023).

Family and social support represented the final major theme and was conceptualized as a continuous element across all 12 sessions rather than as a discrete treatment phase. The expert-derived codes included parental stress, limited parental knowledge of sensory strategies, lack of coordination among caregivers, and the need for consistent home implementation. This is consistent with family-centered occupational therapy literature showing that interventions for autistic children are strengthened when families participate in goal setting, treatment implementation, and generalization (Watling et al., 2023). Family participation is especially important because many of the target behaviors addressed in the protocol, including emotional regulation, sensory modulation, self-care, transitions, and social interaction, occur most frequently outside the clinic. The systemic orientation of the developed program also corresponds with broader family-therapy perspectives emphasizing that child functioning cannot be separated from relational and environmental systems (Robinson, 2025). Similarly, function-based intervention research demonstrates that behavior is more effectively modified when its environmental contingencies and communication functions are considered (Perihan & Bicer, 2021). Thus, the continuous inclusion of parent education, home assignments, and sensory-diet implementation within the present protocol can be considered an important strength of the model.

A particularly significant contribution of the study is the explicit integration of cognitive-behavioral play therapy and sensory integration within a single intervention architecture. Previous research has separately demonstrated benefits for sensory integration, cognitive-behavioral approaches, and play-based interventions; however, these methods are often implemented as independent treatment traditions. Sensory integration has shown potential benefits for sensory, motor, language, and play-related outcomes (Awaida et al., 2024; Fouad et al., 2023; Kuhaneck et al., 2023), while cognitive-behavioral and play-based approaches have demonstrated effects on behavior, anxiety, attention, and social-emotional functioning (Azizi et al., 2020; Hamidifard et al., 2023; Mirghafourian et al., 2022). The present study goes beyond placing these techniques side by side by organizing them according to shared therapeutic targets. For example, sensory preparation precedes demanding cognitive tasks, deep-pressure or proprioceptive input is incorporated before social interaction, and graded exposure is combined with cognitive and emotional coping strategies. This reflects an integrated mechanism in which bottom-up sensory regulation may facilitate top-down cognitive and behavioral engagement. Such integration is conceptually consistent with findings that combined sensory and conventional interventions may offer clinically meaningful advantages for some children with autism (Awaida et al., 2024).

The development of the protocol through Intervention Mapping also strengthens its methodological coherence. Rather than deriving sessions solely from therapist preference, the identified needs were systematically converted into performance objectives, measurable indicators, determinants of change, and intervention activities. Intervention Mapping provides a structured method for connecting empirical needs assessment with program design and implementation (Bartholomew Eldredge et al., 2022). This was reflected in the present study by the progression from initial codes to axial codes, subthemes, main themes, performance objectives, a change matrix, and finally the 12-session protocol. Such a process increases transparency regarding why each intervention component was included and what mechanism it is intended to target. It also facilitates later evaluation because measurable performance indicators can be connected directly to specific therapeutic components.

The content-validity findings provide additional support for the appropriateness of the developed program. All 12 sessions obtained CVI values between .80 and .90, exceeding the accepted minimum threshold of .79. This indicates a high level of agreement among experts regarding the relevance and appropriateness of the session objectives, strategies, activities, and assignments. Member checking further contributed to refinement of the protocol by improving clarity, simplifying instructional procedures, strengthening alignment between therapeutic activities and the theoretical approaches, and modifying the sequence and wording of session objectives. These procedures are important because a conceptually strong intervention may still lack clinical usability if session procedures are unclear or overly complex. The expert-review process therefore strengthened both content validity and practical applicability.

It should also be emphasized that the present study does not claim clinical efficacy on the basis of content validity alone. The findings establish that the intervention is theoretically grounded, systematically constructed, and judged by experts to be relevant and coherent. Previous literature provides indirect empirical support for the components included in the protocol, but the integrated intervention itself requires direct evaluation. This distinction is particularly important given the variability in outcomes reported across sensory interventions and the methodological limitations of some studies. Although several systematic reviews report beneficial effects (Lyu et al., 2025; Oh et al., 2024; Piller et al., 2026), other research has underscored variability in effectiveness according to child characteristics, intervention fidelity, and outcome definition (Randell et al., 2022). Moreover, one study that combined sensory integration training with social sports games has been retracted and therefore cannot be considered valid evidence for therapeutic effectiveness (Wang et al., 2022). The present protocol should therefore be regarded as a rigorously developed intervention framework whose clinical effects must be established in subsequent experimental research.

Conclusion

Overall, the findings support a multidimensional understanding of intervention needs in children with autism spectrum disorder. The eight themes identified in the present study indicate that sensory processing, emotional regulation, cognition, social interaction, motor functioning, daily independence, and family support should not be treated as unrelated domains. Instead, they form an interacting therapeutic system in which change in one dimension may facilitate progress in others. This conceptualization is compatible with contemporary neurodevelopmental and systemic perspectives that emphasize heterogeneity, contextual functioning, and individualized intervention (Morris-Rosendahl & Crocq, 2020; Robinson, 2025). The 12-session spiral structure developed in the present study reflects this interdependence by revisiting the same therapeutic domains across multiple sessions while gradually shifting the emphasis from sensory regulation and therapeutic engagement toward cognitive-behavioral skills, social participation, generalization, and independence. Consequently, the principal contribution of the study is not merely the identification of therapeutic techniques but the organization of those techniques into a coherent, theoretically grounded, developmentally sensitive, and content-validated program.

The present study has several limitations that should be considered when interpreting its findings. First, the research focused on program development and content validation rather than testing clinical effectiveness; therefore, no conclusions can yet be drawn regarding the extent to which the 12-session intervention improves sensory processing, emotional regulation, social communication, cognitive flexibility, motor functioning, or adaptive behavior in children with autism spectrum disorder. Second, the expert panel was relatively small and was drawn from a limited number of academic and clinical settings, which may restrict the diversity of professional perspectives represented in the validation process. Third, although the thematic analysis was based on a broad range of theoretical and empirical sources, the quality, methodological rigor, and populations of the reviewed studies varied. Fourth, some intervention targets within the protocol overlap conceptually, making it difficult to determine whether future therapeutic effects would result from sensory integration, cognitive-behavioral mechanisms, play-based delivery, parent participation, or their interaction. Fifth, the protocol was designed as a general framework for children with autism spectrum disorder and sensory modulation difficulties, despite the substantial heterogeneity of autism in relation to language ability, intellectual functioning, symptom severity, sensory profile, age, and adaptive functioning. Finally, the intervention duration and session structure were determined through theoretical synthesis and expert review and have not yet been empirically optimized.

Future studies should evaluate the clinical effectiveness of the developed protocol using randomized controlled trials with sufficiently large samples and clearly defined inclusion criteria. Experimental studies should compare the integrated intervention with cognitive-behavioral play therapy alone, sensory integration alone, treatment as usual, and wait-list control conditions in order to determine whether the integrated model produces additive or synergistic effects. Researchers should employ standardized measures of sensory processing, emotional regulation, anxiety, social communication, executive functioning, motor skills, adaptive functioning, and parental stress and should include both post-intervention and long-term follow-up assessments. Future work should also investigate moderators of treatment response, including age, verbal ability, autism severity, intellectual functioning, baseline sensory profile, parental involvement, and comorbid emotional or behavioral difficulties. Component-analysis studies would be valuable for identifying which elements of the intervention are essential and which can be modified without reducing effectiveness. Multisite studies should be conducted to determine whether the protocol can be implemented consistently across clinical, educational, and community settings. Qualitative interviews with children, parents, therapists, and teachers could further clarify acceptability, feasibility, perceived mechanisms of change, and barriers to implementation. Future research should also examine treatment fidelity and develop a standardized fidelity checklist for the 12-session protocol so that implementation quality can be monitored systematically.

In clinical practice, the developed protocol may be used as a structured framework for organizing play-based intervention for children with autism spectrum disorder who display concurrent sensory, emotional, behavioral, and functional difficulties. Before implementation, clinicians should conduct an individualized assessment of the child’s sensory profile, communication abilities, cognitive level, motor functioning, emotional regulation, preferred play activities, family routines, and specific functional needs. The intensity and type of sensory stimulation should be adjusted carefully according to the child’s responses rather than applied uniformly. Cognitive-behavioral activities should be adapted to the child’s developmental and language level and presented through visual, experiential, and play-based methods. Parents should be actively involved throughout treatment and should receive clear instructions regarding sensory strategies, emotion coaching, reinforcement, behavioral consistency, and generalization of skills to the home environment. Collaboration among psychologists, occupational therapists, speech-language professionals, teachers, and caregivers is recommended to ensure that intervention goals are coordinated across settings. Clinicians should also monitor the child’s tolerance and progress continuously and modify the sequence or intensity of activities when necessary while maintaining the core therapeutic structure of the protocol.

Authors’ Contributions

Authors equally contributed to this article.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.

Transparency Statement

Data are available for research purposes upon reasonable request to the corresponding author.

Acknowledgments

We would like to express our gratitude to all individuals helped us to do the project.

Declaration of Interest

The authors report no conflict of interest.

Funding

According to the authors, this article has no financial support.

Ethics Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.