Effectiveness of social skills education and sandplay therapy for children with attention deficit hyperactivity disorder and comorbid anxiety

Abstract

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder in school-aged children, often complicated by comorbid anxiety that exacerbates core symptoms and hinders clinical outcomes. Conventional behavioral interventions primarily target external behaviors but inadequately address internalizing issues such as anxiety. Social skills education enhances interpersonal competence, while sandplay therapy facilitates nonverbal emotional expression. We hypothesize that combining these approaches may simultaneously improve behavioral symptoms and emotional distress, offering a comprehensive non-pharmacological intervention for children with ADHD and comorbid anxiety.

AIM

To investigate the efficacy of social skills education combined with sandplay therapy for children with ADHD and comorbid anxiety.

METHODS

Fifty-two children with ADHD and comorbid anxiety were randomly assigned to either a control group receiving routine training or an observation group receiving social skills education and sandplay therapy for 12 weeks. Pre-intervention and post-intervention assessments included the Conners Parent Symptom Questionnaire, Swanson Nolan and Pelham-IV rating scales, Social Anxiety Scale for Children, Screen for Child Anxiety Related Disorders, Piers-Harris Children’s Self-Concept Scale, and number cancellation test. Parental satisfaction was compared.

RESULTS

After 12 weeks of intervention, the observation group showed significantly lower scores than the control group in the Parent Symptom Questionnaire (hyperactivity index, anxiety, conduct problems, psychosomatic problems, hyperactivity/impulsivity factor), Swanson Nolan and Pelham-IV (attention deficit, hyperactivity/impulsivity, oppositional defiantness), and Social Anxiety Scale for Children and Screen for Child Anxiety Related Disorders scales (all P < 0.05). The observation group also showed significantly higher scores than the control group in the Piers-Harris Children’s Self-Concept Scale (physical appearance and attributes, anxiety dimension) and digit cancellation test (number of correct digits crossed out, number of incorrect digits crossed out, and number of missed digits crossed out) (all P < 0.05). Parental satisfaction was significantly higher in the observation group than in the control group (P < 0.05).

CONCLUSION

Social skills education with sandplay therapy may improve core symptoms and anxiety in children with ADHD, enhance attention and self-awareness, and achieve parental satisfaction, suggesting clinical potential.

Keywords: Social skills education; Sandplay therapy; Attention deficit hyperactivity disorder; Anxiety; Children

Core Tip: For children with attention deficit hyperactivity disorder and comorbid anxiety, a 12-week intervention combining structured social skills education with nondirective sandplay therapy significantly alleviated core behavioral symptoms and anxiety, while enhancing attention function and self-awareness. This comprehensive, non-pharmacological approach yielded high parental satisfaction by integrating external skill-building with internal emotional integration, offering a clinically valuable treatment model that addresses both the psychological and social deficits in this complex pediatric population.